Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In which patients with stage IV NSCLC and PD-L1 TPS >50% plus concomitant autoimmune disease is it considered safe to give immune checkpoint blockers?
Given the adverse events of special interest noted with immune checkpoint blockers - specifically immune related AEs (or irAEs), the safety (and efficacy) of using these drugs in patients with pre-existing autoimmune disorders is not entirely clear. To date, most (if not all) studies have excluded p...
Do you incorporate carboplatin into the treatment for triple negative breast cancer?
In the neoadjuvant setting, I recommend the addition of carboplatin in all patients (unless medically contraindicated) with stage IIA or higher TNBC. There are now 3 randomized studies - CALGB 40603, GeparSixto and BrighTNess - that have demonstrated significantly higher pCR rates with carboplatin t...
How do you treat non-resectable carcinoid of the thymus?
As with all neuroendocrine tumors, there is tremendous heterogeneity in disease biology and response to treatment. There are, indeed, some quite slow-growing thymic carcinoid tumors which could be suitable for observation, especially in asymptomatic patients (interestingly, while males affected by M...
Would you offer imatinib to a patient with a high risk GIST (> 10 cm, low Ki-67, s/p complete resection) who initially declined adjuvant therapy, but is now interested 14 months post surgery?
In general adjuvant treatment is usually initiated within 3 months of diagnosis. It would be helpful to know more detail about this GIST. For example, where was it located, what was the mitotic count and was any mutational analysis performed. I am not aware of any data which specifically addresses ...
How would you approach a biopsy proven NSCLC patient with mediastinum negative disease and contralateral suspicious spiculated PET avid nodule without pathologic diagnosis?
This is a scenario I have faced before. Sometimes unfortunately in spite of staging studies, the stage a lung cancer patient has might remain a bit unclear. In this situation if this is a functioning patient with good PFTs who is a surgical candidate I would consider treating him like he has 2 separ...
How do you advise women who are at high risk for breast cancer and for whom annual screening breast MRIs are recommended regarding the long-term risks of gadolinium contrast?
For all breast cancer screening modalities, we need to weigh the benefits for early detection with the potential harms, such as false positive results and over diagnosis. Among young high-risk women with dense breasts, breast MRI has higher sensitivity compared to mammography for early detection of ...
How long do you continue low dose CT screening for lung cancer?
In general, I discontinue LDCT after 3 negative scans for a person undergoing lung cancer screening without symptoms. This is not true if small nodules are seen on imaging. This is based on the best data we have at the time and the possibility of risk associated with continued annual screening. The...
Does CD5 positivity by itself in DLBCL pose a high risk of CNS recurrence and necessitate CNS prophylaxis?
There are convincing data that de novo CD5+ DLBCL does confer a heightened risk of CNS relapse - in the largest series reported, this risk was 12.7% after treatment with RCHOP chemotherapy, and this despite 15% of patients having received intrathecal methotrexate as prophylaxis [https://doi.org/10.1...
How do you approach a patient with a non-castrate testosterone level and rising PSA despite receiving LHRH agonist therapy?
This is a good question. It is always good to check on the testosterone value in men on LHRH agonist therapy in order to ensure the level truly is within castrate range. I assume this patient has been on therapy for a number of months (i.e. the testosterone has had time for full suppression). If so,...
How would you treat an older patient with newly diagnosed B-ALL and significant cardiac and neurological co-morbidities?
Treating older patients with newly diagnosed B-ALL WITHOUT significant comorbidities is challenging enough! There is no accepted standard of care for the treatment of older adults with ALL, typically defined as over the age of 60. Lower intensity chemotherapy backbones with the addition of ABL kinas...