Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach relapsed idiopathic HLH?
If the patient was previously in remission after etoposide and steroids, they may well respond to etoposide and steroids again. I strongly consider hematopoietic stem cell transplant in anyone who relapses after an episode of HLH, since it is usually a harbinger of recurrent and potentially life-thr...
Do you initiate anticoagulation prophylaxis for pediatric patients with vascular compression secondary to solid tumor/lymphoma?
It is an interesting question, but lacks critical details. Of course, most cancers are prothrombotic, and anticoagulation can have risks: Is it arterial or venous compression? Complete obstruction? Acute or chronic? Collaterals? Is it compromising an organ? Is thrombus seen, or is there blood flow?...
What is your preferred chemotherapy backbone (FOLFOX or FOLFIRI) when combining with encorafenib + cetuximab in the 1L setting for BRAF V600E-mutant mCRC?
In my practice, the treatment backbone regimen decision is driven by patient factors - thoughts about hair loss, current bowel function, performance status, existing neuropathy, and other comorbid conditions. All things equal, I prefer FOLFOX. Recent updates from ASCO GI show good activity for FOLFI...
Prior to gender affirming surgery, do you hold estrogen (or convert to transdermal) to minimize postoperative VTE risk?
I'd divide this into 2 sub-questions: what to do in a patient who has a history of thrombosis, and what to do in a patient without a history of thrombosis. In a patient with prior thrombosis, I would generally have them on indefinite anticoagulation alongside ongoing estrogen use. We know that trans...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
Given the emerging benefit of neoadjuvant immune checkpoint inhibitors in selected patients with cutaneous melanoma, when should lymph node basin ultrasound or cross-sectional imaging (CT/PET) be considered prior to wide local excision (WLE) with or without sentinel lymph node biopsy (SLNB) in patients with clinically node-negative disease?
As the current neoadjuvant IO data for melanoma are mainly from SWOG 1801 and NADINA trials, I would say the main patient population to focus on baseline staging scans (i.e., PET or CT) would be those with resectable stage III or IV disease. As it’s not possible to know whether lymph nodes have micr...
What is the current paradigm for breast cancer diagnosed with isolated metastases prior to initial treatment?
Surgery of the primary did not significantly improve overall survival in which patients were randomly allocated to receive systemic therapy alone or (for responding patients) to systemic therapy followed by primary tumor resection in the trial conducted by ECOG-ACRIN (Khan et al., PMID 34995128), at...
Are there reasons to not use prostate SBRT when treating the prostate +\- proximal SV?
Early trials such as HYPO-RT-PC which aimed to validate a 7-fraction SBRT dose schedule by comparing it to the standard of care at the time, conventionally fractionated EBRT, utilized a treatment volume consisting of the prostate alone without the seminal vesicles (SVs). While there was some suggest...
What is the optimal duration of ADT for unfavorable intermediate risk or high risk localized prostate cancer treated with SBRT instead of conventionally fractionated or hypofractionated RT?
There is no available data from randomized trials to support any modification in the choice of ADT (GnRH agonist vs antagonist) or use of abiraterone acetate, or on the duration of ADT (4-6 mo vs 2-3 years) based on the form of radiation, and thus I follow the NCCN guidelines that provide recommenda...