Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
What would be your radiotherapy plan for a patient with recurrent GBM (WHO grade 4, IDH wild-type) s/p 2 prior resections with no prior radiation?
The scenario described in this clinical case is not uncommon. I have had patients who either live several hours away from our center or were unwilling to receive the Stupp protocol of 60 Gy in 6 weeks and were successfully treated with 3 weeks of hypofractionated RT (HFRT). HFRT over 1–3 weeks (25 G...
Should we consider deferring adjuvant chemotherapy for resected early-stage NSCLC in light of COVID-19?
This is a great and timely question! The absolute benefit observed with adjuvant chemotherapy in surgically resected NSCLC is greatest in those patients with stage II and III disease. The question is how long can one wait to give adjuvant chemotherapy and maintain its benefits. Salazar and colleague...
Do you still recommend protons for grade 2 and grade 3 glioma, following the Soprano study results showing a survival detriment?
I should start by saying that I generally do not recommend proton therapy for grade 2-3 gliomas in adults unless there is a clear and specific indication. Modern photon techniques such as VMAT are highly conformal, efficient, and safe, and they form the backbone of the evidence base that guides our ...
What are best practices for dermatologists and oncologists to collaborate in order to optimize multidisciplinary care of patients with high risk CSCC?
A network of specialists familiar with cSCC is necessary to optimize care that is tailored and appropriate for each unique case. Avoiding under-treatment and over-treatment is important, but also challenging, given the high volume of cSCC tumors with variable patterns of presentation and numerous cr...
How are you treating MSI-H CRC in a liver transplant recipient on tacrolimus & sirolimus?
This is an important question; however, our experience in the metastatic colorectal cancer (mCRC) setting remains very limited. This patient underwent liver transplantation three years ago and has since developed dMMR/MSI-H metastatic colorectal cancer. The patient is currently receiving tacrolimus ...
For a patient s/p laryngectomy with positive margins, would you start radiotherapy 6 weeks s/p surgery if there is a delay in concurrent chemotherapy?
The question is a bit challenging without understanding the reason why the patient is suited for XRT but not chemo. My best guesses would be a concurrent infection or PS issues, possibly due to deconditioning after a hard surgery.However, part of the decision would involve when it is anticipated tha...
For patients with locally advanced GEJ adenocarcinoma with low PDL-1 score, will you still incorporate durvalumab with FLOT therapy?
Yes. I would still incorporate durvalumab with FLOT in patients with locally advanced GEJ adenocarcinoma even when PD-L1 expression is low. MATTERHORN was intentionally designed as an all-comers study without PD-L1 selection, and the event-free survival benefit was observed in the overall population...
What is your approach to the management of chronic GI bleeding from AVMs in an elderly patient on DOAC for atrial fibrillation?
I would definitely strongly consider the left atrial appendage occlusion device in these patients. While usually these devices (such as Watchman) do require anticoagulation for about 45 days until the device has an endothelial layer form on it (we usually confirm with a CT scan or TEE), there are so...
In which scenarios would you consider adjuvant CDK4/6 inhibitor use if there is only one ipsilateral axillary lymph node positive for microscopic disease?
For patients with stage II hormone receptor-positive, HER2-negative breast cancer that is grade 3, I would offer adjuvant ribociclib irrespective of whether they are node-positive or node-negative because such patients would be included in the NATALEE trial, and both groups had statistically signifi...