Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In which situations do you consider post-mastectomy radiation therapy when the patient has a localized node-positive breast cancer with a complete nodal response and minimal residual disease in the breast post-neoadjuvant chemotherapy?
This is an area of open study as we await the results of NSABP B-51. Off study at this time, I discuss the role of PMRT with all patients, with cN1 patients with a pCR in the nodes. I discuss PMRT is likely to provide a locoregional recurrence benefit, though survival advantage is unclear. Factors t...
If blood counts are being checked during concurrent chemoradiation, is there a number at which point you would recommend a radiation treatment break?
I’ll let the platelets go as low as 10K before stopping. I lean heavily on the rate of decline to intervene with a break sooner than the absolute numbers if heading for trouble and later if decline is slow and at reaching the end of treatment.
Would you change AR signaling inhibitor in a patient with high volume metastatic castration-sensitive prostate cancer who started darolutamide with initial plan for docetaxel but in whom chemotherapy was eventually deferred?
The ARASENS trial showed a survival benefit for the combination of ADT with chemotherapy and Darolutamide in mHSPC. In a patient with high-volume disease who has been initiated on Darolutamide but in whom chemotherapy was planned but then deferred, I would continue with Darolutamide if the patient i...
Would you offer a patient with MMR-deficient colon cancer who underwent surgical resection of metachronous liver metastases "adjuvant therapy"?
In the general population of colorectal cancer patients with upfront resectable liver metastatic disease with low clinical risk, resection followed by a risk–benefit discussion regarding adjuvant chemotherapy or surveillance is appropriate. Fluorouracil-based chemotherapy compared to observation has...
Do the level of positive lupus anticoagulant titers correlate with the risk of VTE?
The lupus anticoagulant test is either positive or negative. It’s not reported out at a titer. The test needs a two-step confirmation, the first being the addition of mixed plasma to rule out a factor deficiency and the second confirmation being the addition of phospholipids and showing normalizatio...
Do you recommend routinely getting periodic 24-hour urine monoclonal protein study for patients with active multiple myeloma?
In short, no. I like to perform at the time of diagnosis and then at key points in the patient's journey if it was grossly abnormal (at the time of a bone marrow biopsy, for example). Patients definitely do not enjoy it. It does allow for IMWG response assessment, which is mandated for patients on t...
How do you approach a patient with discordant breast cancer risk prediction scores for prevention?
It's not uncommon to come across discordant lifetime breast cancer risk estimates between routinely used risk assessment models such as Gail, TC V8.0, Claus, and CanRisk. These models differ widely in the risk elements, ability to incorporate results from germline panel testing/PRS, and their streng...
Do you consider downstaging neoadjuvant cemiplimab for borderline resectable CSCC in order to facilitate surgical resection?
Very good question. Data from use of neoadjuvant therapy in many solid tumors has shown that when they clinically regress, actual pathologic response is more heterogeneous. Although an area can appear to have a complete clinical response- random biopsies can show areas of viable microscopic tumor st...
Can a patient with MDS have ring sideroblasts in the absence of mutation such as SF3B1?
Yes, < 50% of MDS RS have SF3B1 mutation by NGS. Malcovati et al., PMID 32347921
What scenario would prophylactic Tocilizumab be considered to prevent Ipilimumab+Nivolumab (immunotherapy) induced toxicity in malignant melanoma?
Currently, there is no indication for prophylactic Tocilizumab with the data that is available. As a matter of fact, Tocilizumab is off-label for the treatment of immunotherapy-related toxicities (it’s indicated for the treatment of CAR-T-induced toxicities and cytokine release syndrome, though not ...