Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How long after initiating ADT/androgen blockade is it acceptable to start docetaxel in a patient with high burden, de-novo metastatic HSPC where you are recommending triplet therapy?
In ARASENS, patients were allowed to enroll if they had received no more than 3 months of ADT prior to starting docetaxel +/- darolutamide. The biologic underpinnings suggest that the combination is most likely to be effective if given together. Therefore, I generally prefer to start the patient on ...
Would you consider a PARPi for a patient with PALB2 mutated metastatic triple negative breast cancer?
PARP inhibitors currently have FDA approval for treatment of breast cancer in patients with HER2 negative disease who carry a BRCA 1 or BRCA 2 mutation, but not other familial (germline) genetic mutations and they are not approved for tumor (acquired) genetic mutations. Theoretically, PARP inhibito...
How would you manage a premenopausal patient with HER-2 positive DCIS in the setting of a prior HER-2 positive contralateral breast cancer?
NSABP B-43 looked at the combination of post-op RT + trastuzumab vs RT alone in HER2+ DCIS and while there was a numerically lower number of IBTR events in the trastuzumab arm, this did not reach statistical significance. At this time, we do not manage our HER2+ DCIS patients differently than HER2-....
What is your approach for using anticoagulation/aspirin in patients with multiple myeloma?
Excellent question with lots of nuances but no clear answer. I'll start with my gestalt approach, which is to consider a DOAC for every patient with myeloma if all of the following are true: They are receiving an IMiD (lenalidomide or pomalidomide) They set off my 'spidey sense' with one or more of ...
What is your preferred management for diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH)?
The management of patients with DIPNECH is predominantly symptomatic but DIPNECH is a chronic disease, often with significant respiratory symptoms such as dyspnea and cough but the severity of the symptoms varies over time.I recommend involving pulmonary medicine early on as the management can resem...
Would you substitute carfilzomib in place of bortezomib in a transplant-eligible AL amyloidosis patient with baseline amyloid neuropathy and worsening neuropathy on bortezomib despite maximal dose reduction?
I never give carfilzomib as part of first line therapy on Al amyloidosis. These patients already have some form of cardiac involvement (based on troponin and NT proBNP). 56% of AL amyloid patients have 2 or more organ involvements with cardiac being one of them. Always take into consideration cardia...
How, if at all, does your approach to adjuvant chemoradiation differ with proton beam radiation vs. conventional photon radiation for H&N Cancers?
As there is no prospective data for protons over photons in head and neck cancer, despite the proliferation in utilization, I would not feel comfortable treating this way unless it was the only option.In addition, recent reports indicate a relatively high risk of mandibular ORN, which is hardly seen...
How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?
Our hematologist/oncologist referred just such a patient. No evidence of malignancy, but elevated CRP &ESR. I did an “internist’s” workup as I would for dermatomyositis, starting with the most important and therefore most thorough aspect: taking a full and very “invasive” history, followed by a comp...
For patients with IgG kappa multiple myeloma receiving an IgG kappa mAb (i.e., daratumumab), how important is it clinically to use an interference assay if they're in a VGPR to see if their M-spike might actually be 0?
I always try to perform an assay to distinguish an IgG kappa monoclonal protein from the therapeutic antibody of interest. For daratumumab, the ‘hydra shift’ assay has been used for a while. Now, with Mass spectrometry available, it is the perfect way to assess very sensitively for a residual protei...
Would repeat MMR/HER-2 or NGS testing be beneficial during progression of gastric cancer in patients who have already received first line chemotherapy?
There are really no good data one way or another, as far as I know, so any views expressed here are purely anecdotal and personal opinions.As a group and speaking for myself, I rarely repeat NGS. The bigger picture is that we identify actionable alterations in esophagogastric cancer no more than 5% ...