Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer adjuvant immunotherapy after salvage neck dissection for persistent nodal disease after definitive chemoRT for a patient with p16+ oropharyngeal SCC?
I am assuming that this HPV+ oropharyngeal cancer patient was treated with definitive CRT and then on a 3-month follow-up, PET had persistent nodal disease, which was definitively treated with a neck dissection. If the pathology revealed positive disease, then I would not offer the patient further t...
How do you approach treatment for a patient with T2N0, ER+/PR+, HER2 negative breast cancer with planned TC treatment following a hypersensitivity reaction?
We don't have a trial with albumin bound paclitaxel plus cyclophosphamide vs. TC to guide you here. There is also some conflicting guidance on managing Docetaxel hypersensitivity. On one hand, some references say to rechallenge with Docetaxel is contraindicated (Lenz, PMID 17522249), but if you look...
Will you offer cetuximab or panitumumab with FOLFOX in patients with metastatic left sided RAS/BRAF WT MSS colon cancer instead of bevacizumab?
This is an important question and now we have two studies presented at ASCO attempting to address this. The GONO trial from Italy investigated FOLFIRI or FOLFOXIRI both with panitumumab showing no additional benefit of irinotecan. This was not confined to left-sided tumors but the RR was similar at ...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
Do you typically recommend four factor prothrombin complex concentrate versus fresh frozen plasma for INR correction in patients with vitamin K antagonist associated spontaneous ICH?
Great question! Despite the lack of large randomized controlled trials, PCCs achieve faster reversal of the INR level than FFPs do, and thus I favor using PCCs with Vitamin K as a first line agent for Vitamin K antagonist related ICH.
What is the best course of action for a patient with isolated carcinomatous meningitis who is responding well to intrathecal methotrexate but now has MRI findings suspicious for methotrexate leukoencephalopathy?
Neurological toxicities of intrathecal methotrexate tend to be categorized by the timeline of onset after treatment. Acute MTX toxicity includes arachnoiditis, encephalitis, transverse myelopathy, and seizures. This tends to be readily reversible including neuroimaging findings. Subacute MTX toxicit...
In women of childbearing age with NMDA encephalitis and normal pelvic imaging, is there a role for oophorectomy for possible microteratoma?
Pelvic imaging of female patients with anti-NMDA-receptor encephalitis for ovarian teratoma should consist of MRI of pelvis or ultrasound of pelvis with transvaginal views. If this testing is unrevealing, the recommendation, in general, is not to proceed with oophorectomy. There have been reports of...
How do you approach a BRCA-mutated, premenopausal woman with metastatic ER+, Her2+ carcinoma with progression on THP?
This is probably not a common scenario, but one that theoretically crosses 3 areas of metastatic disease with largely non overlapping clinical trial data. It is somewhat unusual because premenopausal women with ER-positive/HER2 positive breast cancer have disease that is typically sensitive to estro...
Is there a role for any of the CDK4/6 inhibitors in ER+/HER2+ or ER-/HER2+ metastatic breast cancer?
This question is being addressed in clinical trials of CDK4/6 inhibitors. In preclinical studies, CDK4/6 inhibition induces senescence in HER2 positive breast cancer cell lines and there is synergistic anti-tumor activity with combined HER2 targeted agents and CDK4/6 inhibitors. As a downstream targ...