Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you give palliative breast RT to a patient receiving weekly paclitaxel for rapidly progressing metastatic disease?
Given symptomatic disease and need for palliation, I would treat. I would offer 30 Gy/10 fractions. If localized lesion, I would target this with mini-tangents, limiting dose to lung, given concurrent paclitaxel. If involving skin, I would bolus daily.
In a patient with both Stage III NSCLC and another concurrent high risk malignancy, how do you sequence consolidation durvalumab with local therapy for the concurrent cancer?
I pretty frequently see either 1) concurrent LA-HNSCC and stage III lung, or 2) concurrent stage III and stage I NSCLCs. I wouldn't pause or delay the durva in either scenario. Quite a bit of literature now supporting the safety of concurrent RT (even high dose per fraction/SBRT) and immune checkpoi...
Do you recommend starting an antiplatelet for primary prophylaxis in post splenectomy thrombocytosis given there is some increased risk of venous thrombosis?
I do not recommend routinely initiating prophylactic antiplatelet therapy for post splenectomy thrombocytosis. First, in patients without a myeloproliferative neoplasm (MPN), the increase in platelet number post splenectomy is both delayed and mild, and there is no correlation between reactive throm...
Do you initiate management of new onset diabetes in a patient on immunotherapy or refer immediately to endocrinology given the risk of rapid worsening?
New onset hyperglycemia during ICPi therapy warrants careful review of potential risk factors for type 2 diabetes mellitus (T2DM) and close monitoring of symptoms and lab results to distinguish from the rare and typically more threatening checkpoint inhibitor-associated diabetes mellitus (CIADM). Ne...
What is your preferred steroid sparing therapy in a patient experiencing a severe checkpoint inhibitor toxicity and not responding to high dose IV steroids?
There are likely two different questions here: 1) For patients who have responded to steroids, but are unable to taper off (or to a minimally acceptable chronic dose), I have favored mycophenolate as a steroid sparing agent. 2) For patients with severe pneumonitis that is refractory to steroid ther...
How do you manage patients with oligometastatic CRC who have completed 6 months of chemotherapy with favorable response followed by partial hepatectomy, while awaiting resection of the primary tumor?
Approximately 14-25% of colorectal cancer present with synchronous colorectal liver metastatic disease (CRLM). There are three treatment strategies: classic, combined, and reverse. The classic approach is to get the primary tumor resection first then systemic chemotherapy followed by liver metastase...
How would you manage a CLL patient with Richters transformation that is resistant to R-CHOP with transfusion dependent cytopenias and a marrow demonstrating significant involvement by DLBCL and CLL?
Very hard situation. Probably this patient has received BTKi and venetoclax based therapies already. These cases are difficult to treat. There are no standard therapies. Ideally, I try to take them to CAR-T therapy. The challenge is how to collect due to significant cytopenias due to extensive marr...
Would you give IV iron for low TSAT in patients with MDS anemia who are transfusion independent but on an ESA?
Yes. The literature is replete with evidence that iron restricted erythropoiesis mitigates optimal responses to ESAs. It is overwhelmingly likely that an individual receiving erythropoietin or darbepoetin will enjoy longer intervals and dose reduction if the IRE is corrected. I administer a gram of ...
What are your triggers for BM biopsy in polycythemia vera?
We may do a BM biopsy at diagnosis for pediatric patients, but do not generally do them as part of our diagnostic work-up, especially if JAK2 mutant. However, if there is evidence for myelofibrosis (falling counts) or leukemic transformation, we would do a biopsy.
How do you approach treatment for ovarian carcinosarcoma that has progressed during adjuvant carboplatin, paclitaxel, and bevacizumab following optimal tumor reductive surgery?
Recurrent ovarian carcinosarcoma (OCS) is a difficult clinical scenario with few evidence-based options. Clearly, a need exists for novel therapies, and a frank discussion on treatment goals and expectations is warranted. Ovarian carcinosarcoma (OCS) is a rare histologic subtype of ovarian cancer ac...