Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you work up and manage persistent lymphopenia in an asymptomatic patient?
Simple answer: refer to an immunologist, as this degree of lymphopenia is quite likely to represent a serious immunodeficiency. I would also send a next generation sequencing panel of immunodeficiency/immunoregulatory genes to be in process while awaiting the immunology consultation. Long answer (fr...
What is the appropriate time to initiate adjuvant chemo/endocrine therapy for premenopausal ER/PR+, HER2 negative early stage breast cancer with moderate Oncotype following breast conserving surgery?
I would think there is a reasonable window for the chemotherapy to start (which should be given first), perhaps up to as late as 10-12 weeks post op (if it has to be delayed although rare to need to wait that long). Most of the time, we have made the decision to use chemotherapy and have all the nec...
Would you change systemic therapy for metastatic melanoma on BRAF/MEK targeted therapy with excellent extracranial response, but with CNS-only progression?
If a patient is on BRAF/MEK dual targeted therapy with excellent extracranial response, but with CNS progression, I would favor continuing the BRAF/MEK inhibitor therapy and considering SRS to CNS lesion(s). However, if the patient has not received prior combination IO, another option to consider wo...
What are best practices for oncologists during the national platinum shortage?
In breast cancer, we are prioritizing patients with curable disease in which platinum agents are a critical part of the regimen or have actually shown a clear advantage (the only example of this is shown below in bold).Use an alternative to a carboplatin-based regimen whenever possible. If no altern...
How do you manage multiple brain metastases from small cell lung cancer?
In general, I think WBRT is a reasonable treatment for small-cell lung cancer (SCLC) brain metastases. That being said, our institution has considered SRS for select patients depending on a variety of factors as the treatment paradigm for this is evolving. There have been some studies addressing SRS...
How do you modify TNBC neoadjuvant chemotherapy in patients with multiple sclerosis?
This is a good, but tough question with unfortunately no great data to support the safety of immunotherapy combinations in patients with active autoimmune diseases including multiple sclerosis. While the significant improvement in pathologic complete responses with the addition of pembrolizumab to c...
How would you manage a patient pre-operatively with a prolonged PTT that does not correct on mixing, with lupus anticoagulant testing that is abnormal by LA-PTT only?
Not all reagents/assays exhibit the same sensitivity (aka responsiveness) to lupus anticoagulants (LAC). In this case, there is evidence of LAC based on one assay, LA APTT. Often we see prolongation/inhibition in other assays e.g. APTT, but the phospholipid neutralization (PNP) step is not always di...
How would you manage a patient pre-operatively with a prolonged PTT that does not correct on mixing, with lupus anticoagulant testing that is abnormal by LA-PTT only?
Not all reagents/assays exhibit the same sensitivity (aka responsiveness) to lupus anticoagulants (LAC). In this case, there is evidence of LAC based on one assay, LA APTT. Often we see prolongation/inhibition in other assays e.g. APTT, but the phospholipid neutralization (PNP) step is not always di...
Do you screen adults in your practice with sickle cell disease for silent cerebral infarcts?
The details of the ASH guidelines regarding adults are complex. It was not my practice to screen all patients. More than 50% of adults have silent infarction. Screening requires MRI and this, according to the guidelines, needs careful attention to many details before it is reliable. There are no pro...
Would you restart prophylactic anticoagulation in a patient with a history of unprovoked PE who received short term anticoagulation with a prior physician?
The decision on duration of anticoagulation should balance the risk of hemorrhage vs risk of recurrent VTE. The annual risk of recurrence with unprovoked venous thromboembolism (VTE) is definitely higher than provoked VTE and seems to be higher in males than females.According to one study (Rodger et...