Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In a patient with Waldenstrom's macroglobulinemia doing well and feeling better on ibrutinib & rituximab, but with a rising IgM, do you switch treatment or continue?
A lot depends on the pace of increase of the IgM and the line of therapy. If the pace is rapid, I would think about changing therapy. If the pace of increase is small and the patient is asymptomatic, you could continue a little longer. If planning to changing therapy, it may be reasonable to restage...
Is it safe to continue/re-challenge oxaliplatin in patients with oxaliplatin-induced hepatic sinusoidal injury and splenomegaly?
Typically, if there is documented hepatic injury, I will not revisit oxaliplatin as continued therapy will result in continued injury that may limit future therapeutic options. Given that many GI oncology patients will receive multiple agents that are metabolized through the liver and/or have hepati...
Do you routinely order double-hit assessment in cutaneous DLBCL?
There are certainly reported cases of primary cutaneous DLBCL that harbor double-hit mutations. Guidelines do not distinguish the workup of cutaneous DLBCL from other sites, and if a skin DLBCL were to be of germinal center immunophenotype with IHC expression of myc and bcl2 and/or bcl6, FISH would ...
Are you categorically using lenvatinib over sorafenib for unresectable HCC in the absence of contraindications?
I have done that is recent patients, yes. I am doing it because "on paper" I see better PFS and better ORR, of course in addition to the non-inferiority when compared to sorafenib in the randomized trial that is now published. However, I am building experience with respect to tolerance in my particu...
Would you offer a mid-treatment transition from transtuzumab to TDM-1 for a patient already on 1 year of adjuvant trastuzumab who met criteria for adjuvant TDM-1 based on the KATHERINE trial?
The question is if the patient is er positive or negative. Most patients with residual disease are ER-positive or HER-2 positive. If the patient was ER-positive I would discuss switching vs. neratinib and go through the pros and cons of both.
Would you recommended adjuvant endocrine therapy for a high grade DCIS, ER negative, but PR positive that has underwent lumpectomy and adjuvant radiation?
I would not recommend adjuvant endocrine therapy to a patient with high grade DCIS that was ER-negative and PR-positive. Studies such as NSABP B-23 failed to demonstrate a benefit to the addition of tamoxifen to chemotherapy in patients with ER-negative invasive cancers, which has been confirmed on ...
Would you resume durvalumab after several month hiatus due to IO unrelated medical comorbidities that has since resolved?
This is a challenging question and it is hard to know what the right answer is. If the patient's ECOG PS is good, Durvalumab was well tolerated for the most part, and the IO unrelated medical co-morbidities are now under control, I would consider re-initiation of Durvalumab. I would balance risk and...
Do you offer consolidation thoracic radiation after atezolizumab, carboplatin, and etoposide for extensive stage small cell lung cancer?
I have not had the opportunity to treat a patient yet with carboplatin plus etoposide plus atezolizumab. This regimen is not yet FDA approved (as of 2/18/19) to treat patients with extensive stage small cell lung cancer. However, when it becomes FDA approved, I will plan on offering this regimen to ...
Would you recommend re-excision in a breast cancer patient who received neo-adjuvant chemotherapy with no residual tumor on pathology, but sterile mucin at the edges was present?
In the absence of viable invasive tumor cells at the tumor margin or in the absence of DCIS < 2mm from the margin, I wouldn't recommend re-excision. I would accept the excellent result of a pathologic complete response and that the presumed needed adjuvant radiation would be an excellent approach.
When chemotherapy is indicated in early stage soft tissue sarcoma, would you prefer to use AD or AI?
I would start by bringing caution to the phrase, "when chemotherapy is indicated in early stage sarcoma." I assume you are asking about adjuvant chemotherapy, and will provide comments with that assumption. The role of adjuvant chemotherapy in resected soft tissue sarcomas remains controversial, and...