Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach less common cutaneous/mucosal toxicities from EGFR TKI and monoclonal antibody therapies, such as ocular (keratitis and conjunctivitis) and genital mucositis (vulvovaginitis and balanitis)?
I have a patient with metastatic colon ca who was on pembrolizumab for ~16 months with NED who developed grade 3 oral/upper GI mucositis felt to be an autoimmune AE after extensive work-up. He very gradually responded to high dose prednisone followed by a slow taper that took several months due to f...
How would you manage multiple myeloma with a suboptimal response to frontline quadruplet therapy?
A suboptimal response, i.e. less than PR, to 4-drug induction is likely a poor prognostic sign, I just don't know how poor. This does not mean that you should follow induction with a tandem autologous transplant, CART, or bispecific as we don't know whether it's better than just moving forward with ...
Do you think there is any compelling data to support giving brentuximab as frontline therapy for pediatric patients with Hodgkin lymphoma?
Yes and no. It is clear that you can cure patients with pediatric HL without the use of brentuximab vedotin. While I believe it is safe and effective, if it is not covered by insurance, I would not advocate for its use in low and intermediate risk pediatric patients.However, for HR pediatric patient...
In a patient with metastatic clear cell RCC who achieved a prolonged PR with first line nivolumab/ipilimumab, discontinued due to IRAEs, would you consider a TKI/checkpoint inhibitor combination regimen?
The question of the utility of IO after IO in mRCC is an important one that has not yet been adequately studied. As of now, I believe single agent VEGF TKI is standard of care in this setting (or perhaps lenvatinib/everolimus). There are some retrospective data about Ipi/nivo after prior IO with som...
How do you approach the use of low-dose aspirin for primary prevention in non-pregnant patients with SLE and positive aPL antibodies, without clinical criteria for APS?
I personally do not put all asymptomatic SLE patients with aPL labs on low dose aspirin. This is a somewhat controversial topic. Most of the data we have are from observational studies and results are mixed in regards to efficacy of low dose aspirin for primary prevention in this population. SLE pat...
Would you recommend surgery or radiation for newly diagnosed localized prostate cancer diagnosed on a urethral lesion biopsy?
I think the underlying question here is whether its urethral location changes the recommendations we would otherwise make, and really it doesn't. Let's talk it through: I don't feel that the urethral location affects my ability to treat this with EBRT as the urethra gets the same (curative) dose as ...
Do you routinely perform next-generation sequencing on otherwise "low-risk" GIST to guide adjuvant therapy?
Yes and no. Defining the molecular make up of a newly diagnosed GIST is recommended and helpful in defining therapy. But the mutational status generally does not dictate adjuvant therapy. That decision is based on clinico-pathologic factors and if "low-risk" based on those criteria, close observatio...
How would you adjust therapy for a patient with high risk, stage III choriocarcinoma (lung mets) in the context of renal insufficiency (Cr 3.8)?
Risk score might dictate chemo regimen. There are dose adjustments for Methotrexate & Cytoxan based on renal function for MAC which you could use if risk score 7 or 8. I’d follow MTX levels & dose folinic acid until nontoxic MTX levels. If higher score I’d use EMA +/- CO. Consider neupogen on off-ch...
How do you manage testosterone replacement therapy-induced erythrocytosis?
Testosterone is a known risk for thromboembolism. What is not known is whether it is the hematocrit or the testosterone itself that is the trigger for thrombosis. Note also that epidemiologically, the age group that generally is prescribed testosterone also has a high prevalence of thrombosis. My ap...
How would you approach the treatment of metastatic cholangiocarcinoma after progression on gemcitabine/cisplatin, FOLFOX, and pemigatinib?
This is a tough situation. Depending on the patient's performance status and organ function, a clinical trial is strongly recommended. If the patient has FGFR2 fusion or chromosome rearrangement with prior exposure to pemigatinib, resistance mutation (gatekeeper mutation) is likely present and may b...