Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Are there any special considerations for treating CML in the very elderly, greater than 85 years old?
When approaching older patients with CML it is important to consider comorbid conditions, medications, organ function, and potential toxicity of therapy. This approach is not that different than it would be for younger patients. However, older patients are more likely to be on more medications or to...
What systemic therapy would you consider, if any, for an isolated but multifocal CNS recurrence of HER2+ HR negative breast cancer treated with local therapy (>4 lesions treated with resection and SRS)?
There is not an agreed-upon standard approach, nor am I aware of definitive data supporting one approach over another. My preferred approach to managing isolated CNS relapses that are treated locally with no visible systemic disease is to do trastuzumab plus a TKI with no chemo (like EGF104900 regim...
Would you consider adjuvant chemotherapy for concurrent early stage NSCLC in ipsilateral separate lobes, or do you consider them as separate primaries?
This situation can arise when a patient undergoes lobectomy for primary lesion but has sublobar/wedge resection of a separate nodule in a different lobe with pathology showing the same histology. If both are very early stage and no nodal involvement or other indications for adjuvant chemotherapy, I ...
Would you start neoadjuvant treatment with immunotherapy or BRAF/MEK inhibitors in a patient with a large regional inoperable BRAF V600E positive melanoma (IIIC)?
I prefer to start with BRAF inhibition, as the response rate is quite high, then ask the surgeon to complete the surgical resection after 3 to 6 months of therapy if the patient has a response, and usually offer adjuvant immunotherapy afterwards. If the patient does not respond, I would switch to ip...
How would you manage a patient with history of clear cell RCC >4 years ago who has a solitary oligometastatic brain lesion that is asymptomatic and too small for stereotactic radiation?
I've not encountered a CNS lesion too small for SRS. Sometimes, very small abnormalities are uncertain and are watched, but usually, they are big enough to be diagnostic and treated. If that's the only site of disease, I would do SRS then observe that patient.
Do you offer surveillance brain imaging for patients with EGFR+ NSCLC, stable systemic disease on TKI, and no history of metastatic brain disease?
There are very few data based on randomized trials but we know that the brain is a major site of progression even with osimertinib so I get a brain MRI every 6 months.
How do you approach the pharmacologic management of cancer-related fatigue?
After the above considerations mentioned in the question, management considerations regarding cancer-related fatigue depend on the stage of disease (advanced/metastatic disease vs not) and whether the patient is on active cancer therapy. For both groups, non-pharmacologic interventions have the high...
What maintenance treatment would you recommend for Ph positive ALL following Hyper-CVAD, transplant eligible or ineligible?
While ABL kinase inhibitors (TKIs) are commonly recommended as maintenance post-transplant in Ph+ ALL, the data supporting this practice are relatively soft. Position statements from expert panels convened by EBMT (Giebel et al., PMID 27309127) and ASTCT (DeFilipp et al., PMID 31446198) both general...
How do you approach B-cell lymphoblastic lymphoma (without bone marrow involvement) in older adults (>65-70 years)?
Lymphoblastic lymphoma is more commonly (probably 90-ish%) of T lineage, so this is a relatively rare presentation of an already rare disease. Regardless of age and distribution of disease involvement, B lymphoblastic lymphoma is typically treated with ALL regimens. However, this guidance is less he...
Would you recommend adjuvant therapy for a patient with intraheptic cholangiocarcinoma with an isolated metastasis who has undergone complete surgical resection and is NED?
Given M1 disease, I would absolutely give adjuvant therapy. Data is of course strongest with 6 months of Capecitabine, but given that you could consider this patient metastatic, it would not be wrong to give 6 months of gem/cis. I would also absolutely profile with NGS, to be prepared for recurrence...