Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Outside of a clinical trial, how do you approach upfront therapy for a PDGFRA D842V-mutant GIST?
These are usually indolent surgical tumors (until they are not) that belong in the care of a sarcoma center and not in the community. There are two trials of agents that are being tested for D842V mutations at this time (NCT02508532 and NCT02847429).
What are your treatment recommendations in a patient with de novo metastatic prostate adenocarcinoma with neuroendocrine differentiation?
Neuroendocrine prostate cancer more often arises as a mechanism of treatment resistance than de novo, but in either case, portends aggressive disease biology and androgen insensitivity. Similar to the features of “aggressive-variant” prostate cancer described by Aparicio et al., PMID 26546618, the d...
What is the ideal period to wait until curative surgery for patients with acute pulmonary embolism and solid malignancy?
This is a very important and practical question. As with most clinical circumstances, there is no evidence-based recommendation. The approach will vary with individual situations. For example: 1) Incidentally discovered subsegmental PE: my bias would be to proceed with curative surgery after one mon...
What is the ideal period to wait until curative surgery for patients with acute pulmonary embolism and solid malignancy?
This is a very important and practical question. As with most clinical circumstances, there is no evidence-based recommendation. The approach will vary with individual situations. For example: 1) Incidentally discovered subsegmental PE: my bias would be to proceed with curative surgery after one mon...
Do you or your institution use a creatinine clearance value calculated by actual, ideal, or adjusted body weight for chemotherapeutics dosed by creatinine clearance?
Hello, at our institution, we typically use creatinine clearance value calculated by actual body weight for chemo dose calculations; but of course, factors such as hydration status/trend of change in Scr, etc. are considered before making a decision.
How would you approach a fit older (>70 years) with grade I-II, bulky, follicular lymphoma causing ureteral obstruction and renal failure?
You could also consider focal radiotherapy as we know follicular lymphoma is often very radiosensitive (and can respond quickly to RT). Depending on the trajectory of the AKI and dysfunction, I would discuss with my urology colleagues to see if there is any role for ureteral stenting to see if kidne...
What recommendations would you make for a patient on long-term phenytoin due to epilepsy with a newly diagnosed breast cancer requiring doxorubicin as part of her chemotherapy?
Change to Keppra and use doxorubicin.
Do you use breast MRI or ultrasound to assess tumor size prior to neoadjuvant chemotherapy in breast cancer?
Either is reasonable. Most often, patients being considered for neoadjuvant therapy have palpable tumors that can easily be followed by PE. Both MR and US could be repeated to guide surgical planning. While MR has become popular, it is less clear that margins are more likely to be negative at initia...
Which patients with Stage II-III lung adenocarcinoma, in whom you are considering neoadjuvant chemoimmunotherapy, can you rely on liquid NGS to exclude driver mutations in lieu of repeat tissue biopsy?
I think we always have to do our best to ensure we have adequate NGS. If tissue-based NGS on the initial biopsy is inadequate or negative, then a liquid biopsy is a good next step. However, if the liquid biopsy is negative for driver mutations, I would have a thorough discussion with the patient abo...
How has the ASCENT trial impacted your management of previously treated metastatic TNBC?
The phase III ASCENT trial demonstrated improved progression-free survival and overall survival with sacituzumab govitecan over single-agent chemotherapy of physician’s choice (TPC) in metastatic triple-negative breast cancer (mTNBC). All the sub-groups derived benefit, including <65 vs >=65, initia...