Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach patients with locally advanced nasopharyngeal squamous cell carcinoma post induction chemotherapy with gemcitabine/cisplatin and imaging showing mild progression?
Yes. Assuming there is no distant metastatic disease now, I would continue with the plan for locoregional control (curative intent) chemoradiation with RT and cisplatin. This was the schema/regimen used in the most recent several large reported randomized studies from China/Taiwan and has been used ...
Would you offer empiric radiation for a growing mediastinal mass radiographically suspicious for thymoma in a patient who declines surgery?
If the patient truly refuses surgery, they need to undergo a core biopsy to get a tissue diagnosis due to the variety of potential histologies (ranging from thymoma, thymic carcinoma, lymphoma, germ cell tumor, primary lung tumor, etc.) each requiring distinct management strategies. Even...
How do you approach patients with unresectable pancreatic cancer on gemcitabine/nab-paclitaxel-based chemotherapy q28 days with severe neutropenia?
I always give gem-nab-pac every other week from the outset. So I rarely run into this issue, and when I do, it is easy, on a q2 week schedule, to add pegfilgrastim.
Would you still recommend bone marrow biopsy in an elderly non-transplant eligible patient with mild cytopenias if NGS from peripheral blood indicates MDS mutations?
Yes. The presence of mutations in peripheral blood is not diagnostic of MDS. The elderly can have CHIP mutations and mild cytopenias which qualify for CCUS rather than MDS. CCUS has a higher risk for progression to MDS but is not MDS by itself. Would get a bone marrow prior to diagnosing MDS and sta...
How do you manage drug-drug interactions between oral anticoagulants and the ARSI agents such as apalutamide and enzalutamide?
Commonly used oral anticoagulants, such as apixaban, rivaroxaban, and warfarin are substrates of hepatic cytochrome P450 enzymes (CYP). Co-administration of an AR signaling inhibitor (ARSI) variably affects the concentration of those drugs depending on the effect on the type of CYP enzymes. For exam...
Is there strong evidence to use TMB found in circulating tumor DNA to guide the use of ICI in metastatic colon cancer?
The benefit of immunotherapy for patients with high TMB was demonstrated in the KEYNOTE 158 study (Marabelle et al., PMID 32919526). This is a phase 2 study that enrolled 1076 patients with advanced solid tumor (a total of 10 different tumor types including anal, biliary, cervical, endometrial, meso...
Will you now recommend enfortumab and pembrolizumab for most patients with metastatic urothelial carcinoma, regardless of platinum eligibility, based on the EV 302 presentation at ESMO 2023?
The data presented at ESMO were paradigm-shifting. Within the constraints of insurance coverage, I will offer EVP to all patients with untreated metastatic urothelial cancer who are otherwise candidates for this therapy.
Is it okay to send an Oncotype solely for prognostic purposes to a patient who doesn't want chemotherapy or an elderly patient with poor PS?
It isn't a matter of wrong or right in these scenarios you are asking about. Assuming they meet clinical criteria to order the test, it is more important to discuss how the patient and you would react to the prognostic information especially if it is high risk. If the patient has a clear idea about ...
How would you approach the treatment of an elderly patient with multiple myeloma and CALR+ myelofibrosis with elevated platelets?
Thank you! This is a great question and a very complicated case. Generally, I would be less concerned about thrombocytosis. I would focus more on the symptoms and splenomegaly that the patient may be experiencing. If they are not having significant MF-related symptoms or splenomegaly, then observati...
Would you consider a FAST-forward fractionation for a cT1a IDC with DCIS that was found to be pTis on lumpectomy specimen?
I do consider FAST-Forward for patients > 50 years old following breast conservation. In this situation given invasive disease, I am comfortable with no tumor on ink even with associated DCIS.However, if otherwise acceptable, I would offer this patient PBI (30/5) rather than FAST-Forward. If for som...