Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to the management of essential thrombocytosis in a woman planning to start a family?
This is an important question because it directly addresses what it means for a patient to have an MPN, and what it means for the physicians who treat them. The first is diagnosis: what is essential thrombocytosis (ET)? Some “experts” state that it is “related” to polycythemia vera (PV), or represen...
How do you manage de novo high volume mCSPC with both BRCA2 mutation and MSI-H on somatic testing?
This is a very rare but interesting scenario. Presumably in this case, the BRCA2 mutation is a passenger event in the setting of high TMB as a result of MMRD/MSI high disease, which has been reported. Typically these BRCA alterations are monoallelic and the tumors lack homologous repair deficiency a...
How would you approach a locally advanced ampullary carcinoma with BRCA1 mutation whose Whipple showed complete pathologic response after 5 cycles of neoadjuvant mFOLFIRINOX?
I assume this patient has pancreaticobiliary-type ampullary cancer. Unfortunately, no data to support adjuvant PARP agent. With BRACA positive status, one could complete the total of six months of treatment with gem/abraxane/cisplatin.
For patients who progress to mCRPC on ADT+ARSI started in mCSPC setting, do you continue the ARSI if patients have had a mixed response?
A "mixed response" can mean many things and the specific circumstances are critical for decision-making here. For example, bone scan flare, or pseudoprogression, with new unconfirmed lesions, is quite common with ADT/ARSI therapy and should not be a reason for treatment discontinuation as per PCWG2/...
How would you manage a patient with metastatic HCC on atezolizumab/bevacizumab who requires holding bevacizumab due to persistent proteinuria >2g?
This is a great clinical question, one that we often see since the approval of atezolizumab/bevacizumab in first line setting for HCC. Incidence of proteinuria with bevacizumab has been reported anywhere from 0.8%-4% for grade 3 (more than 3.5 g in a 24-hour urine protein level) (Brandes et al., PMI...
For a Jehovah's Witness patient with multiple myeloma, could you safely offer a BCMA-directed bispecific antibody or CAR-T therapy?
Short answer is - yes! Long answer is - it depends. Patients can be optimized leading into CAR T-cell therapy by using ESAs and possible TPO agonists, iron, B12, folate supplementation. The main issue is around propensity for anemia and thrombocytopenia, especially if profound and prolonged. Patient...
Would you extrapolate from EMBARK to use an ARPI other than enzalutamide in high risk biochemically recurrent prostate cancer for a patient with contraindications to enzalutamide?
This is a good question and my general answer is no, as no other ARSI has a phase 3 trial in this nmHSPC setting showing similar benefits. PRESTO was a smaller phase 2 trial of ADT/apalutamide but did not measure or report MFS or OS and was underpowered to look at these endpoints. However if a patie...
Would you offer adjuvant osimertinib in a patient with complete pathologic response to neoadjuvant platinum doublet for a stage IIIA resected EGFR mutant lung adenocarcinoma?
With the caveat that we do not have level I evidence specifically for this clinical scenario yet (ongoing NeoADAURA study may potentially provide some answers in the future), based on very favorable outcomes of patients with NSCLC in general who derived pathologic complete response after neoadjuvant...
Is a bone marrow necessary in patient with splenomegaly and polycythemia vera?
Yes. Bone marrow is necessary in a patient with polycythemia vera and splenomegaly. There is a possibility of missing ET or associated primary or secondary myelofibrosis. The only way to distinguish between the three bcr-abl negative MPN namely MF, ET, and PV is by performing a bone marrow biopsy an...
What strategies have you found to be most effective in engaging PCPs in a primary-care or shared-care model of survivorship for pediatric and AYA patients who will receive ongoing care in their communities away from their primary oncology treatment site?
This is a challenge for our center, and many other centers as well. The ideal approach would be to have adult primary care physicians associated with our center who have dedicated clinic time to care for cancer survivors, direct access to our expertise and medical records. While we haven't been succ...