Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Which systemic therapy (if any) do you offer premenopausal women with a second TNBC local resectable recurrence and an extensive chemotherapy history?
Patients with locoregional recurrence definitely benefit from repeated chemotherapy for sure (as shown in CALOR trial and our own experience). The question here is after exhausting anthracycline and taxane-based therapy as most patients would have been already, what might be the best regimen? The f...
How do you approach the treatment of ITP in a pregnant patient who did not respond to prednisone?
We usually stay away from dex because of the toxicity and use the absolutely smallest dose of prednisone we can. Usually, unless the count is very low, I start at about 20mg since we’re just trying to get the count up not get a CR. We manage a lot of patients with IVIg alone, but it can get expensiv...
Would you consider 177Lu-Dotatate (Lutathera) in patients with midgut neuroendocrine carcinoma after treatment with a somatostatin analog but with Ki67 >20%?
PRRT with Lu-177 DOTATATE can certainly be considered in patients with well-differentiated G3 NETs. The expected outcomes are not as favorable as with G1/G2 NETs but better than with poorly differentiated G3 neuroendocrine carcinoma (G3 NEC) where PRRT should probably not be used at all unless in th...
How do you counsel peri- or post-menopausal women diagnosed with HR+ breast CA who wish to continue receiving testosterone supplementation?
The first question I would ask is, what symptoms is this woman treating by taking testosterone? There are a paucity of randomized trials using testosterone, in various preparations (transdermal, gel, intravaginal DHEA) in breast cancer survivors. One double placebo-controlled trial studied subcutane...
Would you pursue adjuvant immunotherapy for a resected stage IIIC or IIID, BRAF wild type, melanoma patient with pre-existing ulcerative colitis that is well managed on maintenance infliximab?
Obviously, a challenging situation. In short, no. Risk:benefit ratio in this setting, I believe, is too high as the risk of bowel perforation is real. If recurrence does occur and surgery is not an option, can schedule infliximab infusions prior to anti-PD-1 therapy. I have been able to minimize fla...
Would you consider tamoxifen to be contraindicated for chemoprevention in patients with a history of OCP induced VTE?
Absolutely, yes. SERMs are contraindicated in women who have a history of thrombosis and in women who are pregnant, planning to become pregnant, or are breastfeeding. SERMs are also relatively contraindicated in patients with increased risk of thrombosis, such as those who smoke or have a familial p...
How would you manage a stage IE DLBCL of the stomach, non-germinal center type by IHC, and Ki-67 of 70%, but negative for double/triple hit by FISH?
Nijland et al., PMID 29083044. This shows that you can use either option, 3 cycles RCHOP+ XRT or 6 cycles RCHOP with no difference in relapse or DFS.My bias would be to treat with 6 cycles of RCHOP as I look at DLBCL as a systemic disease and risk for systemic relapse even with early presentation.If...
When do you consider iron chelation in elderly patients with transfusion-dependent MDS?
When the ferritin is >1500 or if LFTs due to iron are abnormal between 1250-1500. You have to be careful with chelation at lower levels due to chelation of other micronutrient heavy metals.
Would you initiate chemoimmunotherapy (e.g. RCHOP) in a symptomatic patient with DLBCL who tested positive for COVID19?
It will depend on if he is symptomatic from covid infection or just positive but asymptomatic. If asymptomatic from covid, I would treat. DLBCL is the one which is symptomatic and active disease without treatment is equally immunosuppressive. I would suggest giving rituximab with cycle 2 rather than...
How would you manage an incidentally identified 1.0 mm anal squamous cell carcinoma (5.5 mm margin) in a background of severe dysplasia/CIS involving the peripheral excision margins found on a hemorrhoidectomy specimen?
T1 anal margin cancers can be adequately treated with local surgical excision if negative margins (> 1cm) can be accomplished without compromise to the adjacent sphincter muscles and no evidence of nodal involvement. In this specific case, I would recommend thorough examination via anoscopy with bio...