Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you counsel patients regarding initiation of total parenteral nutrition (TPN) with malignant small bowel obstruction?
The answer we give to this question symbolizes how we think about treatments to be offered to a patient near the end of life. Thus, these answers often say as much about us as they do about our patients or medical science. In my experience, conversations around things like TPN toward the end of lif...
What would be your choice for re-induction in a young patient with FLT3+ refractory AML after 7+3 induction therapy with no FLT3 mutation on the day 14 marrow?
I would use a 5+2 regimen with midostaurin and would not put much stock in an absent FLT3 mutation at day 14. If there had been no cytoreduction, some would switch to another chemotherapy regimen but there is little data for that especially in an FLT3+ AML. We are not told what the degree of respons...
How do you manage hand-foot syndrome associated with capecitabine (and other conventional chemotherapy agents)?
In the breast cancer world, I see hand-foot syndrome most commonly with capecitabine. I have used topical 10% urea cream with a reasonable amount of success. I have noticed that using it prophylactically seems to help with the prevention of hand-foot syndrome to quite an extent. A couple of randomiz...
What would be your choice of therapy in a fit patient with relapsed CLL previously treated with bendamustine and rituximab who does not want BTK inhibitor therapy?
I am assuming that this individual who has relapsed was receiving initial therapy with bendamustine rituximab is a young, under 65 years of age, CLL patient who does not prefer to have a BTK inhibitor. This is not an uncommon situation given the increasing knowledge of the chronic low-grade toxiciti...
For PDL1 testing in triple negative breast cancer, is CPS by 22C3 equivalent to SP142 Ventana?
The short answer is that 22C3 is not equivalent to SP142. There are cases that are double-positive but 22C3 positive and SP142 negative cases exist. While benefit from atezolizumab and nab-paclitaxel seems to be seen for SP142 positive breast cancer (based on the results of IMpassion130 trial), the ...
What is your preferred choice and timing of systemic therapy in a patient with high risk oligometastatic prostate cancer undergoing metastasis directed therapy to all sites of disease, including the prostate?
Metastasis-directed therapy (MDT) is an option for patients with oligometastatic prostate cancer who wish to delay initiation of ADT, based on STOMP (Decaestecker et al., PMID: 25223986) and ORIOLE (Phillips et al., PMID: 32215577) trials. In the STOMP study, 61% of patients (3 or fewer metastases) ...
How would you approach the treatment of metastatic colon cancer with pathologic features indeterminate between adenocarcinoma and small cell carcinoma?
Mixed adenoneuroendocrine carcinomas of the colon (MANEC) can be collision tumors, composite tumors, or in this case, amphicrine tumors whose cells contain morphologic features of both. If the neuroendocrine component was grade 3, I would treat it as small cell carcinoma with etoposide/platinum.A re...
Is a patient with secondary myeloid sarcoma a candidate for hematopoietic stem cell transplant?
There are circumstances where these patients would be candidates for stem cell transplant. The extramedullary presentation is thought to be a high-risk feature and many of these patients will have a relapse in marrow or other sites, so a stem cell transplant done after remission is achieved may help...
For a metastatic neuroendocrine tumor patient who has experienced prolonged progression free survival, how would you approach surgical debulking?
This is a complicated answer (especially for me as a medical oncologist...). The main factors to consider are the tumor grade, tumor behavior, extent and location of metastases, patient's age and performance, and the location of the primary tumor. For a patient with a G1/G2 pancreatic or SB NET with...
How do you risk stratify complex karyotype in newly diagnosed multiple myeloma in the absence of specific high-risk cytogenetic abnormalities?
Complex karyotype with >3 abnormalities is high risk independent of high risk FISH abnormalities. It tells you that the cancer cell is able to divide in culture and that is a bad sign as they are able to survive outside the marrow. It typically portends a highly proliferative signature of myeloma si...