Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you avoid the use of a TNF inhibitors in patients with a remote history of melanoma, including those with ocular melanoma?
Clinical trials of TNF inhibitors have identified a small but increased risk of malignancy with the use of TNF inhibitors, and most, but not all, of the follow-up studies done with real-world registries have confirmed this. These registries are of course sometimes affected by the behavior of physici...
Would you add tucatinib to systemic therapy for ER+ HER2+ metastatic breast cancer, where there is systemic control but new brain metastasis?
The patient has progressive disease in the brain, which will require treatment -- the standard of care option would be local therapy in the form of radiation +/- surgery. Data from HER2Climb suggests that the combination of capecitabine + tucatinib + trastuzumab controlled disease in the CNS for 9+ ...
How would you approach adjuvant therapy for a high-risk stage III colon cancer which is MSI-high in a patient >70 years of age?
First, MSI-H stage III colon cancer patients will benefit from oxaliplatin-based adjuvant chemotherapy (Jin et al., PMID 33467526). This is different from stage II MSI-H colon cancer (we do not recommend adjuvant chemotherapy for these patients). Second, oxaliplatin seemed to be an important compone...
How long would you wait after palliative short course radiation (i.e. 30Gy / 10 fractions) in metastatic NSCLC before initiation of chemo-immunotherapy?
I haven't typically waited for a specific period after short courses of palliative radiotherapy to start chemo-immunotherapy, if the patient has recovered from side effects from radiotherapy and is ready to start systemic therapy otherwise. Hopefully, data from studies and trials to better inform us...
Would you offer radiation alone to localized recurrence of extensive stage small cell lung cancer while on maintenance immunotherapy or would you start alternative systemic therapy?
The role of local therapy for the treatment of patients with ES SCLC has been evaluated in a number of phase 3 trials. The first trial, which was published by Jeremic et al., PMID 10561263 over 20 years ago, reported a survival advantage for adding thoracic radiation to chemotherapy compared with ch...
What is the role of radiation in a patient with stage IV DLBCL with bilateral testicular involvement?
I tend to loosely recommend consolidation RT to the testicles in this situation if in CR. This recommendation is based on pattern-of-failure studies in primary testicular lymphoma where prophylactic contralateral testes RT is usually recommended, and the principle that the testicles are a sanctuary ...
How would you manage a middle aged woman with history of severe alcoholic liver cirrhosis and a small node negative ER/PR positive, HER2 negative breast cancer?
It is always critical to weigh absolute harms against benefits for any medical decision-making to the extent possible - ideally using validated tools when available/applicable. This should include factoring in co-morbidities and performance status. In the case of severe liver dysfunction - competing...
At what level of bone marrow disease would you agree to proceed with transplant for a patient with refractory AML?
Most transplant centers will settle on 5% or fewer blasts by morphology or flow cytometry as the cutoff for transplant. Exceptions or leeway is sometimes given for those undergoing myeloablative/full-intensity conditioning, and those with primary refractory disease. MRD typically refers to disease t...
What is the utility and recommendation for adding troponin and/or BNP to echocardiograms to screen for cardiac dysfunction In breast cancer patients receiving anthracycline based regimens?
For a healthy woman who received a total cumulative dose of 240 mg/m2 of doxorubicin, nothing more than a baseline echocardiogram is needed. JCO put out a clinical practice guideline in 2017 (Armenian et al., PMID 27918725) that covers the prevention and monitoring of cardiac dysfunction in survivor...
How do you approach patients with unresectable NSCLC planned for concurrent chemoradiation who develop a serious infusion reaction to paclitaxel?
There are a number of options to consider:1. Platinum-etoposide is a well-established regimen and alternative standard for concurrent chemoradiation for many years.2. For patients with nonsquamous histology, while the PROCLAIM study did not meet its study endpoint showing superiority compared to cis...