Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you mitigate 6-MP-induced GI toxicity in pediatric and AYA patients with leukemia?
This is a great question as GI toxicities are commonly encountered in children, adolescents, and young adults being treated with 6MP including elevated transaminases, pancreatitis, and hypoglycemia. These GI toxicities are likely due to a skewing of 6MP metabolites with an accumulation of the GI tox...
Do you consider the duration of lung/lobar atelectasis in your decision making while offering airway stents for malignant central airway obstruction?
Yes, always. We review old imaging to determine when there is a post obstructive pneumonia or collapsed lobe/lung secondary to endobronchial obstruction (extrinsic or intrinsic). The old teaching was that, if a lobe is down for more than two months, it is unlikely to be salvaged, even after the endo...
How would you manage a transplant-eligible patient with DLBCL who relapsed 6-12 months following a CR1 to R-CHOP and then attained a CR2 to platinum-based salvage chemoimmunotherapy?
In this case, given that the patient obtained a CR2 to salvage therapy, I would, if they are otherwise eligible, take this patient to transplant given the data presented by Shadman et al., PMID 34570879 which indicates that those with at least a PR from salvage chemotherapy appeared to benefit as mu...
What gene mutations do you always test for prior to starting EGFR inhibitor therapy in metastatic colon cancer?
At a minimum, I operate with pan-RAS, BRAF (yes, even for left sided tumors), MMR/MSI, RNA fusion/rearrangement, and HER2 testing prior to anti-EGFR therapy. Obviously, you would not want to give an EGFR inhibitor to a RAS mutated cancer, but similarly, I need to know the BRAF (particularly V600E) u...
In clinically metastatic lung cancer with bone predominant disease, do you routinely biopsy the bone to prove metastatic involvement, knowing that bone biopsies are generally not ideal for molecular testing?
If patients have diffuse disease, I do not biopsy bone lesions to confirm bone involvement if imaging studies are very suggestive. I do refer patients with an otherwise local or locoregional disease with bone lesion that is suspicious, since that would change the stage and management.
How can oncologists be more collaborative with palliative care physicians?
First and foremost, for oncologists to be collaborative with palliative care physicians, a trusting relationship is a must (good communication amongst teams is key to optimal patient care). This is akin to PCP-Oncologist (or even PCP-any other specialist relationship). Before advances in science and...
When, if at all, is it appropriate to re-challenge a patient with a EGFR inhibitor in metastatic RAS/BRAF WT colon cancer?
Following the MD Anderson data presented several years ago by Parseghian et al., PMID 30462160 regarding successful rechallenge after the resistant RAS/EGFR clones decay from detection in the blood, I do utilize ctDNA profiling primarily at times of progression with the intent of rechallenging. Anec...
Would you consider complement inhibitor therapy or immunosuppressive therapy (e.g. cyclosporine, corticosteroids) for a patient with a PNH clone and early MDS who presents with pancytopenia?
It would depend on the size of the PNH clone and whether or not it was the dominant process as suggested by the depth of the cytopenias and whether there is evidence of hemolysis. I've seen a number of patients with MDS who are concurrently diagnosed with a small PNH clone and I have directed my tre...
How would you approach a patient with metastatic colon cancer with biopsy-confirmed bone mets who has a significant decrease in CEA on FOLFOX but develops new bone lesions?
I would assume that the bone lesions became more apparent on imaging due to a response from chemo and not because this is true progressive disease. (See Costelloe et al., PMID 20842228) They were likely there at initiation rather than this being a true mixed response. I would trust your tumor marker...
How do you approach patients with recurrent BRAF negative melanoma and resected oligo-metastasis after completing one year of adjuvant nivolumab?
This is an important question with no direct randomized data to guide therapy decisions. There are a few factors that need to be considered, such as whether the progression happened while on anti-PD1 therapy versus following completion; whether recurrence was loco-regional versus distant, etc. If th...