Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the role of upfront pembrolizumab in metastatic PD-L1 positive NSCLC presenting with SVC syndrome?
This is a "trick question" as there are at least 3 difficult questions hidden here- Can systemic therapy replace the need for local therapy in urgent clinical situations traditionally calling for radiation? What is the best upfront treatment regimen for a patient with PD-L1 positive NSCLC? What is t...
What growth factor would you use with A+AVD, if any at all?
When treating patients with Hodgkin lymphoma with either ABVD or A-AVD I decide if their risk of febrile neutropenia is likely to be more than 20%, which, therefore, includes some patients on ABVD and most patients on A-AVD. For such patients I give GCSF (filgrastim, grastophil) on days 6-11 after e...
Do you ever consider the use of weekly (as opposed to bi-weekly bortezomib) for newly diagnosed multiple myeloma patients who are transplant eligible?
Is it necessary to hold immunotherapy during a 4-6wk steroid taper after resolution of immunotherapy related toxicity?
This is an excellent question. Most of the clinical trials with checkpoint inhibitors required complete taper of steroids prior to rechallenging wtih immunotherapy following toxicity. As we use immunotherapy in the clinic, and have utilized combinations with chemotherapy, including regimens that use...
Would you offer further systemic therapy to a patient with triple-negative breast cancer treated with neoadjuvant chemotherapy, BCT, and adjuvant capecitabine who has a local failure while receiving capecitabine?
Given how quickly she recurred locally on capecitabine, her tumor cells must be resistant to it, so I have little enthusiasm to continue this treatment, nor do I advise exposing her to other chemotherapy drugs with little likelihood of benefit. The SWOG trial is one idea, if she's eligible. Would al...
How do you decide which lab to use for multi-gene hereditary testing?
Many commercial companies offer multi-gene panel testing for cancer susceptibility genes. The decision about whether to choose small, medium, and large multi-gene panels depends upon the patient's personal and family history of cancer and also personal preferences. Larger panels have higher rates of...
How do you approach the subsequent management of a patient with appendiceal adenocarcinoma (T4bN2M1a) with completely resected single peritoneal and omental deposits?
This is a largely data-free zone when it comes to prospective trials but many excellent retrospective studies exist on the topic. There are data (NCDB, institutional and others) to suggest a benefit of adjuvant therapy (see Asare EA et al. Cancer 2016;122:213-21). I would look carefully at the grade...
What is your approach to genetic testing for high risk patients?
At our center, clinical assessment initiated at diagnosis and anybody who meets the NCCN criteria is referred to genetic counsellor
How do you treat a young woman of child bearing age group diagnosed with primary CNS lymphoma?
The first step is to check HIV serology to ensure that the patient is HIV negative as HIV+ve patients would need to antiretroviral therapy promptly along with chemotherapy or the prognosis is dismal. If patient is young and fit the initial approach is similar in both HIV +ve and -ve patients. Assumi...
Would you give adjuvant chemotherapy to a post-menopausal woman with strongly ER/PR positive locally advanced lobular carcinoma with >3 axillary LNs?
If she has no medical contraindication to chemotherapy, yes. And assuming she has no contraindication to treatment with an anthracycline, I would favor an AC-T sequence, in either order (my preference is to give the taxane first, which is usually less toxic and causes less or no stem cell damage tha...