Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach the treatment of patients with von Willebrand disease or hemophilia A previously managed with intranasal DDAVP during the recall?
There are two separate questions here, one is easy and one complicated. Desmopressin challenges can be performed with intravenous desmopressin, 0.3 mcg/kg. It is not necessary to challenge a patient with IV who previously responded well to the nasal preparation, in my view. How to approach treatme...
How would you approach bone-only metastases in a postmenopausal woman with HR+/HER2+ breast cancer currently on anti-HER2+/AI maintenance?
If you are convinced that her metastatic disease has progressed on her prior treatment, would consider a couple of options, including T-DM1, presumably with discontinuation of endocrine therapy (am not aware of any studies looking at T-DM1 +/- endocrine therapy in ER+/HER2+ patients). Another option...
Is antiplatelet or anticoagulant therapy preferred for the secondary prophylaxis of cryptogenic stroke in a patient with underlying malignancy?
Will look at the stroke radiographically. If appears embolic and the patient is low risk for bleeding, with respect to their cancer regimen, co-morbidities, and labs, I will discuss off-label anticoagulation with eliquis. If there are additional, chronic embolic appearing strokes - that will also sw...
How would you treat a patient with metastatic renal cell and ESRD on dialysis?
It is now well recognized that patients with CKD, including ESKD on dialysis, are at increased risk of cancer of the native kidney(s). Patients with localized disease are candidates for local therapy or surgery. For metastatic disease, selection of an agent, dose adjustment, and timing in relation t...
How do you manage patients on atezolizumab/bevacizumab with advanced HCC who develop arterial thrombosis?
Arterial thrombosis such as coronary artery events or CVAs is an indication to discontinue bevacizumab. Patients with arterial thrombotic events within the past 6 months should not be treated with bevacizumab; events older than 6 months do not represent a contraindication, especially if the patient ...
For patients with HCC receiving atezo/bev, would you advise any other clinical investigations scheduled during treatment other than basic lab monitoring?
In the IMBrave 150 study, the most common serious toxicity in the AB arm was GI bleeding. And everyone was required to have their varices both evaluated and treated. It’s not convenient, but get the EGD before starting treatment!
Is anticoagulation a relative contraindication to atezolizumab/bevacizumab for advanced HCC?
Anticoagulation is considered safe with bevacizumab unless the patient has an increased of bleeding; as such, any varices should have been adequately treated before treatment with atezolizumab/bevacizumab; I would also avoid anticoagulation and atezo/bev concurrently in patients with platelet count ...
For a patient with previously relapsed TTP but in clinical remission, what is the role of rituximab in treating asymptomatic ADAMTS13 deficiency to prevent relapse?
A very good and interesting question. In remission, there is no question that severely deficient ADAMTS13 activity (<10%) is a strong risk factor for relapse. In patients with a chronic relapsing TTP history (at least 2 episodes), the approach most commonly has been to treat them preemptively with r...
Would you consider maintenance immunotherapy following chemoradiation for a patient with an isolated mediastinal recurrence of NSCLC?
For patients with loco-regional recurrent NSCLC treated with definitive chemoradiation, I would offer durvalumab consolidation since I would consider this on-label treatment (i.e inoperable stage III NSCLC - even TxN2 - treated with definitive chemoradiation). Other nuances of N2 NSCLC in the era of...
How strongly you would recommend surgery in case of distal squamous cell esophageal cancer who completed chemo/RT and achieved CR?
This scenario presents a number of competing concerns. In general, the practice of our group is to consider observation for patients who achieve a clinical complete response (cCR) to chemoradiation, based on 2 European studies that show no clear improvement in OS for esophagectomy in patients with e...