Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is a bone marrow biopsy necessary in a patient with a previous tissue diagnosis of plasmacytoma or smoldering multiple myeloma, who now meets criteria for active myeloma?
It depends. If it is a solitary plasmacytoma with no other lesions, a bone marrow biopsy would offer 2 things: (1) if there is bone marrow involvement, you know that systemic therapy is needed and it is not a solitary plasmacytoma and (2) if you can not get a myeloma FISH panel on the plasmacytoma b...
How do you approach patients with a new primary melanoma, not an in-transit metastasis, while on adjuvant immunotherapy/treatment for a previous melanoma lesion?
This is tough because of the paucity of data to answer the question. In my practice, I recommend patients who develop a new primary melanoma undergo standard-of-care therapy for the new melanoma (e.g., WLE +/- SLNB).
Would you include HER2 directed therapy in the treatment of HER2+ small bowel adenocarcinoma?
I have not encountered any HER2-positive small bowel carcinoma but would consider, it will be reasonable to use HER2-targeted treatment in later line setting (after oxaliplatin/irinotecan-based chemo). There is very limited data and possibly the only study with this population would be in the MyPath...
Would you use adjuvant pembrolizumab for bilateral ccRCC with R1 resection?
It would depend on the pathology of each resected tumor, but my initial thought is that I would not. My concern would be that renal function is likely reduced and nephritis (although rare) could have significant consequences. Certainly, genetic counseling should be considered for all bilateral tumor...
How do you approach the discussion with a patient who is seeking proton therapy for early stage breast cancer?
I would ask why they want protons. Assuming they give the expected answer, I would say something like this: “Thanks for asking about that. I certainly understand why you might feel as if protons would be better for you. I understand that receiving radiation can be scary, and indeed, radiation can be...
Should patients with co-existing moderate-severe valvular disease (particularly AS and MS) and malignancy requiring radiation therapy undergo more frequent surveillance surface echocardiograms?
The answer is yes, for some patients with baseline moderate to severe valvular heart disease receiving radiation, with the heart in the radiation field (i.e. left breast, lung, esophageal cancers), they should have more frequent surveillance echocardiograms.The 2020 ACC/AHA valve guidelines recommen...
How would you treat a metastatic pure urethral adenocarinoma?
The treatment of rare or unusual urologic tract tumors remains an area of active investigation to optimize approaches. In general, most practitioners would utilize a GI malignancy-focused regimen for a metastatic urothelial tract pure adenocarcinoma (mucinous/or enteric type) such as FolFox off of a...
What is your preferred first line approach to patients with Stage IV non-squamous NSCLC with good performance status, no driver mutations, PD-L1 low-positive, and CKD IIIB or worse, CrCl < 45 mL/min?
This is a common scenario. For patients with PD-L1 high tumors, would certainly, of course, feel comfortable with ICI monotherapy. For squamous NSCLC with PD-L1 low or negative, the question is more straightforward since taxane can be given in the setting of renal insufficiency. For nonsquamous NSCL...
Do you recommend continued PCR testing in a CML patient who underwent allogeneic stem cell transplantation with an identical match about 20 years ago?
If the patient was transplanted in chronic phase and has not experienced relapse post alloSCT nor h/o BCR-ABL1 Q-PCR/FISH positivity post alloSCT, I do not believe that there is much value for continuous PCR testing 20 years later as the vast majority of the relapses occur the 1st few years post all...
What chemotherapy regimen would you use for a woman with pre-existing neuropathy causing imbalance, who now has a T1N0 ER+ and Her2+ breast cancer?
If the tumor is T1c, you can consider AC x4. Afterwards, single-agent Herceptin could be considered.