Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach B-cell lymphoblastic lymphoma (without bone marrow involvement) in older adults (>65-70 years)?
Lymphoblastic lymphoma is more commonly (probably 90-ish%) of T lineage, so this is a relatively rare presentation of an already rare disease. Regardless of age and distribution of disease involvement, B lymphoblastic lymphoma is typically treated with ALL regimens. However, this guidance is less he...
Would you recommend adjuvant therapy for a patient with intraheptic cholangiocarcinoma with an isolated metastasis who has undergone complete surgical resection and is NED?
Given M1 disease, I would absolutely give adjuvant therapy. Data is of course strongest with 6 months of Capecitabine, but given that you could consider this patient metastatic, it would not be wrong to give 6 months of gem/cis. I would also absolutely profile with NGS, to be prepared for recurrence...
Would you avoid the use of a TNF inhibitors in patients with a remote history of melanoma, including those with ocular melanoma?
Clinical trials of TNF inhibitors have identified a small but increased risk of malignancy with the use of TNF inhibitors, and most, but not all, of the follow-up studies done with real-world registries have confirmed this. These registries are of course sometimes affected by the behavior of physici...
Would you add tucatinib to systemic therapy for ER+ HER2+ metastatic breast cancer, where there is systemic control but new brain metastasis?
The patient has progressive disease in the brain, which will require treatment -- the standard of care option would be local therapy in the form of radiation +/- surgery. Data from HER2Climb suggests that the combination of capecitabine + tucatinib + trastuzumab controlled disease in the CNS for 9+ ...
How would you approach adjuvant therapy for a high-risk stage III colon cancer which is MSI-high in a patient >70 years of age?
First, MSI-H stage III colon cancer patients will benefit from oxaliplatin-based adjuvant chemotherapy (Jin et al., PMID 33467526). This is different from stage II MSI-H colon cancer (we do not recommend adjuvant chemotherapy for these patients). Second, oxaliplatin seemed to be an important compone...
How long would you wait after palliative short course radiation (i.e. 30Gy / 10 fractions) in metastatic NSCLC before initiation of chemo-immunotherapy?
I haven't typically waited for a specific period after short courses of palliative radiotherapy to start chemo-immunotherapy, if the patient has recovered from side effects from radiotherapy and is ready to start systemic therapy otherwise. Hopefully, data from studies and trials to better inform us...
Would you offer radiation alone to localized recurrence of extensive stage small cell lung cancer while on maintenance immunotherapy or would you start alternative systemic therapy?
The role of local therapy for the treatment of patients with ES SCLC has been evaluated in a number of phase 3 trials. The first trial, which was published by Jeremic et al., PMID 10561263 over 20 years ago, reported a survival advantage for adding thoracic radiation to chemotherapy compared with ch...
What is the role of radiation in a patient with stage IV DLBCL with bilateral testicular involvement?
I tend to loosely recommend consolidation RT to the testicles in this situation if in CR. This recommendation is based on pattern-of-failure studies in primary testicular lymphoma where prophylactic contralateral testes RT is usually recommended, and the principle that the testicles are a sanctuary ...
How would you manage a middle aged woman with history of severe alcoholic liver cirrhosis and a small node negative ER/PR positive, HER2 negative breast cancer?
It is always critical to weigh absolute harms against benefits for any medical decision-making to the extent possible - ideally using validated tools when available/applicable. This should include factoring in co-morbidities and performance status. In the case of severe liver dysfunction - competing...
At what level of bone marrow disease would you agree to proceed with transplant for a patient with refractory AML?
Most transplant centers will settle on 5% or fewer blasts by morphology or flow cytometry as the cutoff for transplant. Exceptions or leeway is sometimes given for those undergoing myeloablative/full-intensity conditioning, and those with primary refractory disease. MRD typically refers to disease t...