Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
What clinical factors impact your upfront treatment decisions in transplant-ineligible MM?
My approach is to start with up-front adjustments in choice of drugs, dose, and schedule based upon many factors: age, organ function/other comorbidities, concurrent medications, insurance/other economic factors, personal physical mobility, and access to transportation, patient goals, etc.Myeloma tr...
Are there any circumstances in which you would recommend adjuvant chemoradiation for resected olfactory neuroblastoma?
Agree with Dr. @Dr. First Last. Our experience treating 29 patients with Kadish B and C neuro esthesioneuroblastoma with local RT if positive margins, and no neck RT when the neck was N0, resulted in 27% neck failure including in the contralateral neck. 5-year LRF rate was 29% in patients who did no...
What is your approach to platelet transfusion in heparin induced thrombocytopenia?
In general, I avoid giving platelets in intensely prothrombotic disorders, except in the circumstance of severe bleeding. Severe thrombocytopenia is uncommon in HIT, though DIC may occur in some patients. However, bleeding is relatively uncommon and platelets not generally necessary.
How would you treat a patient with metastatic clear cell renal cancer who has progressed on immunotherapy and developed bleeding on cabozantinib?
This is not an uncommon situation. Any VEGFR inhibitor can indeed raise the risk of bleeding. An answer depends on the details of the bleeding-like one episode vs ongoing chronic bleeding, severity, arterial vs venous, location, GI vs CNS vs elsewhere, other contributing factors like anti-coagulants...
What dose of PEG-asparaginase do you recommend for teens with high BMI treated on a pediatric ALL regimen?
The peg-asparaginase dosing we use in ALL regimens for B and T cell is below: Patients less than 21 years old – 2500 units/m2 Patients 21 years and older – 2000 units/m2 For obese patients (defined as > 95% BMI for patients less than 20 years old or BMI > 30 for patients 20 years and older), ...