Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you recommend radiation to a painful rib fracture in a patient with multiple myeloma on systemic therapy with ongoing response to treatment?
It depends if it’s a newly diagnosed MM setting versus relapsed MM setting with a rib fracture. Some possible scenarios: For the ND setting, systemic therapy with adequate pain management early on is preferred. For relapsed setting, if the rib fracture heralded the relapse then systemic therapy/pai...
How would you manage primary breast osteosarcoma?
Osteosarcoma of the breast is a rare and highly aggressive tumor, accounting for less than 1% of all primary breast malignancies. Due to its infrequent occurrence, there is a lack of prospective studies to determine the best treatment approach and most publications are case reports. Instead of focus...
How do you approach CLL in a patient not currently on treatment who has a solid tumor that requires treatment?
This is a very pertinent question for all of us who treat patients with CLL. Patients with CLL mostly are elderly in age. Second cancer occurs more often in one with CLL than in the population without CLL. These second cancers can be in any organ, but the frequent sites are skin, GI tract, and lung...
How do you interpret discrepancies between MMR testing and MSI testing?
Microsatellites are short repetitive sequences of 1 to 6 base pairs of DNA throughout the genome, mostly in noncoding regions. MSI tumors develop through a distinctive molecular pathway characterized by genetic instability in microsatellite DNA repeat sequences. MSI phenotype occurs due to germline ...
If an average-risk, physically fit, resected stage II colon cancer patient has a positive signatera result (3.2 MTM/ml), would you recommend adjuvant chemotherapy?
A Positive Tumor-informed assay like signatera is not just a prognostic or predictive marker, but more so signifies PERSISTENCE of disease. A stage-2 average risk is not average risk anymore once you have a positive ctDNA result. Maybe in the future, the TNM would be revised to say TNM-MRD (Stage-2 ...
Do you routinely incorporate G-CSF with chemo if you experience neutropenia after the first cycle of chemotherapy?
I am a GI oncologist, but I would say I have two approaches. One is to use prophylactic GCSF or similar agents upfront with cycle 1 with regimens with high rates of myelosuppression (20% or higher rates of neutropenic fever), like FOLFIRINOX or FOLFOXIRI/bevacizumab. The other approach I have is to ...
How would you treat a patient with colon cancer that is dMMR/MSI-high with a solitary liver lesion that is deemed resectable?
In patients with dMMR/MSI metastatic synchronous liver only resectable adenocarcinoma of the colon, synchronous or staged colectomy with liver resection or checkpoint inhibitor immunotherapy followed by synchronous or staged colectomy with liver resection are guideline recommended options. (NCCN Gui...
Do you consider resuming Venetoclax for patients with CLL upon progression/recurrence, in whom Venetoclax/Rituximab achieved CR and Venetoclax was previously well tolerated but stopped after completing 2 years of therapy?
Yes, in such situations in clinical practice, retrying venetoclax is entirely appropriate. How long has the patient been off prior exposure to venetoclax is a factor to consider, more than 2 years would make me more apt to retry venetoclax. Whether the patient has been given BTKi in the past and ha...
How would you manage a provoked blood clot for a patient who had been placed on low dose DOAC for history of unprovoked blood clot?
To clarify the scenario: the patient had an unprovoked VTE for which they are currently on low dose DOAC and now have experienced recurrence in association with a well-defined (as outlined in ASH guidelines Ortel et al., PMID 33007077) provoking event. A number of additional variables would weigh in...
How are you managing patients with H&N cancers meriting definitive concurrent chemoRT during cisplatin shortages?
If cisplatin cannot be used, other systemic therapies should be considered. The NCCN guidelines list various regimens, as noted below. Given the improvements in the delivery and quality of radiation therapy, I am a believer that single agent carboplatin (AUC 6 Q 3 weeks or AUC 2 Q weekly) can be sub...