Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For locally advanced NSCLC with additional synchronous NSCLC primaries in the same lung or lobe, what is your approach to definitive therapy?
This is a situation that comes up surprisingly frequently and can be challenging to navigate. This assumes that one is certain which of the two lung lesions is the primary (i.e. based on discordant pathology or genomic profiling results of the nodal metastasis and/or first primary compared to the se...
What is your preferred first line treatment for metastatic follicular dendritic cell sarcoma?
This entity saddles the lymphoma-sarcoma group of tumors. Typically treated with SOC Rx for lymphoma first before considering sarcoma-specific regimens.
How would you approach a patient with imaging and labs suggestive of potentially resectable cholangiocarcinoma when several core biopsies reveal bridging fibrosis with no malignant cells?
I believe the first step would be presenting the patient's imaging and case at a multidisciplinary tumor board for input, especially from GI and surgical oncology, ideally at a higher volume center. You don't specify the route of prior biopsies but I am assuming they are percutaneous. Perhaps yield ...
How do you manage neuropathic chemotherapy agents in patients with underlying multiple sclerosis?
I would make sure that if they do have B and T cell immunosuppressive effects (I would check their FDA access data records, phase 3 clinical trials, other drug sites that detail their MOA) and I am convinced that my MS drugs (if the patient is on any) are not needed, I would discontinue such therapy...
Should a pregnant woman who is heterozygous for factor V Leiden who has never had a thrombotic event receive prophylactic anticoagulation?
This is a common situation and lacks evidence based recommendations. Recent ASH guidelines (Bates et al., PMID 30482767) suggest against routine antepartum prophylaxis in this situation. However, it is important to have a balanced discussion with the patient. In my experience, most would choose prop...
How would you approach therapy for a patient with non-seminomatous germ cell tumor, cT3N3Mx and symptomatic lower extremity thrombus extending to the IVC when it is unclear if bland or tumor thrombus?
This is not a common setting, but it is well described and high volume centers have fairly uniform approaches to patients presenting with caval thrombus. With the pre-orch HCG of 850, he is likely IGCCC good risk unless he is found to have brain or hepatic mets. He is likely non seminoma with a larg...
What are your top takeaways from ASCO GU 2022?
My top abstracts and questions that arise from them: 1) ARASENS with darolutamide in high volume de novo mHSPC showing an OS benefit with darolutamide over ADT/docetaxel. Will this pertain only to high volume/risk patients who are chemo-fit and de novo which seemed to comprise the vast majority of ...
How would you approach breast cancer screening in an adolescent patient with a CDH1 mutation?
The timing of initiation of breast cancer screening in an adolescent female with a germline CDH1 pathogenic variant will depend on family history. Initially, I follow the NCCN guidelines which recommend starting screening mammograms +/- breast MRIs annually at age 30. If there is a family history of...
How do you approach heparin management in patients who have suprathetherapeutic Xa levels on minimal heparin?
Assuming heparin is administered using standard weight-based dosing, that the infusion rate is being accurately monitored, and that the assay was done properly, very high anti-Xa levels that persist despite lowering the heparin dose would be most unusual. In that setting, I would suspect that either...
What is your experience with using Frailty Index or other geriatric screening in making decisions for elderly patients with multiple myeloma?
The IMWG frailty score is the most comprehensive score developed to date. While predictive, trials testing its value prospectively are ongoing. Linking age, comorbidities (Charlson), and functional scales (ADL & IADL) makes great logical sense. I don't use it. The UKMRA Myeloma XIV FiTNEss [Frailty-...