Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you recommend COVID vaccination in patients with antiphospholipid antibody positivity or other prothrombotic states not on anti-coagulation?
There are hypothetical reasons that the COVID-19 vaccine might increase thrombophilia in individuals with APS/APLAs. However, the only controlled study I could find, Absence of hypercoagulability after nCoV-19 vaccination: An observational pilot study by Campello et al., PMID 34246010 did not show a...
Would you offer additional adjuvant FOLFOX for patients with rectal CA undergoing TNT who transition to cape/RT and subsequent surgery early due to absence of clinical response to FOLFOX?
Given the number of treatment approaches to rectal cancer, it remains one of our biggest challenges in terms of extrapolating from the larger evidence base in colon cancer.While the stage isn't given for the patient, let's assume they have a cT3N1 low rectal cancer and a TNT strategy is selected. If...
How would you manage VTE in a patient with bleeding disorder such as hemophilia?
Management of VTE in a patient with an inherited bleeding disorder depends on the specific disease, the severity of the bleeding disorder, and the past history of bleeding in that patient. In patients with serious past bleeding and low levels of factor, anticoagulants may be contraindicated and loca...
What factors do you take into account for recommending chemo/IO vs IO/IO vs CheckMate 9LA regimen in front line therapy for PD-L1 negative advanced squamous cell carcinoma?
As others have noted, the HR for the squamous subset of NSCLC seems to suggest that these patients benefit most from combined ICI, seen in both the CM227 and 9LA studies (with the caveat that comparator is chemotherapy alone which is now outdated.) In CM227, the HR for nivo-ipi vs chemo was 0.53 in ...
How do you manage trastuzumab emtansine peri-operarively?
T-DM1 hasn't been shown to impair wound healing, etc. The biggest concern would be simple thrombocytopenia, so I just check CBC prior to the surgery and try to have that scheduled and the week 2 or 3 point after treatment where plts are less likely to be affected. I am assuming this question refers ...
In what circumstances would you give G-CSF to a patient with severe neutropenia and HLH?
I am not aware of any direct clinical evidence that addresses this question. That said, I would be very reluctant to treat with G-CSF in the setting of HLH. G-CSF is an inflammatory cytokine that might aggravate HLH. Moreover, since the mechanism of neutropenia in HLH is thought to be increased neut...
How would you approach synchronous early stage NSCLC adenocarcinoma and locally advanced symptomatic squamous head and neck cancer that is deemed nonresectable upfront?
I would appropriately stage both cancers. If there is no mediastinal involvement, and head and neck is locally advanced- would favor local treatment of lung cancer (surgical or SBRT- expect quick recovery and no delays) while planning for concurrent chemo radiation to head and neck. Further details...
What factors do you look at while deciding between a daratumumab-based quadruplet induction versus standard triplet induction such as VRd for newly diagnosed MM?
This is becoming an increasingly thorny issue. A few guidelines to keep in mind:1) Dara-VRd has only been studied (thus far) in transplant-eligible patients. So this discussion of Dara-VRd vs. VRd is hard to apply to patients without intent for transplant. 2) When you look at the CASSIOPEIA and GRIF...
What adjuvant therapy would you recommend for a T3N0, grade 3, undifferentiated sarcoma of the mandible with positive margins that is not amenable to re-resection?
Not much in the mandible is unresectable. I would get the patient a second surgical opinion with an experienced ENT surgical oncologist. Regardless of use of RT, R0 margins are necessary for optimal local control in STS so would want to evaluate for any possibility of re-resection. (A nuance to this...
How would use of adjuvant pembrolizumab after nephrectomy for ccRCC impact your treatment choice for metastatic recurrence?
I think treatment selection after recurrence/metastases will depend on the timing after adjuvant pembrolizumab has been completed. If it's about 9 months or more, I think re-challenge with pure IO/IO combination is fair, especially if a patient tolerated pembrolizumab well. If it's within 3-6 months...