Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How are you timing the third dose of the COVID-19 mRNA vaccine in patients on rituximab?
At this point, I am advising the patients to do the 3rd vaccine at least 5 months after the previous Rituximab dose. Whenever feasible, I test them for B cell reconstitution prior to vaccination, and may delay the vaccination if B cells are undetectable.
How would you manage early-stage low rectal cancer in a patient unable or unwilling to undergo surgery?
This patient may have multiple non-TME alternative options. Trans-anal excision with or without post-op CRT based upon pathological risk factors would be one option. Alternatively, CRT as part of a non-operative management/watch and wait strategy is also associated with favorable outcomes. Here are ...
How would you approach patients with resected, node positive (N1/N2) Large Cell Neuroendocrine Carcinoma of the Lung who have ESRD on dialysis?
This is certainly a challenging situation, both because of the relative scarcity of data for LCNEC in general as well as the limitations placed in patients with organ dysfunction including requirement of HD.First issue is the question of adjuvant treatment for LCNEC. The role of adjuvant chemotherap...
How would you manage a nodal recurrence of cutaneous SCC if the patient is unable to receive surgery for 6-8 weeks?
I’d first consider referring the patient to a center that could perform the operation, as it is standard of care for a patient with resectable cSCC with nodal metastases. At some centers, there may be a clinical trial of neoadjuvant immunotherapy that could be considered. If those options were not...
Would you add a PARP inhibitor to bevacizumab maintenance for a patient with a high grade serous ovarian cancer with a germline BRCA2 variant of unknown significance and negative somatic testing?
The information above is insufficient in informing a treatment recommendation. As defined, the implications of the BRCA2 VUS are unclear. In this setting, I would advocate that HRD testing be performed on the tumor tissue. If the tumor is HRD+, I would certainly counsel the patient on the utility of...
What regimen would you offer a young patient with T-cell ALL who recurred a short time after allo-transplant and was initially treated with CALGB10403?
The answer is always clinical trial if feasible. If only commercial options: Assuming morphologic relapse, I tend to favor peg-asp containing regimen if the patient is fit enough to receive – especially if ETP variant. I like SMILE, but important to stress that regimen may come with considerable mye...
For colorectal cancer, would you consider using capecitabine 5 days on, 2 days off instead of the usual 2 weeks on, 1 week off or 1 week on, 1 week off schedules?
The 14-day (q21d) schedule for cape was always difficult yet Roche did not wish to address it. The 7-day q14 day was an attempt to give a higher dose density, which is possible but not necessary. Personally, I use 7-day dosing frequently. Just as we do not need to give prolonged infusions of 5FU, pr...
What is your preferred regimen for metastatic clear cell RCC following progression on IO/TKI?
Patients with progression after IO-based therapies are increasingly common. Standard options include single agent TKI (cabozantinib most commonly used after axi/pembro) and lenvatinib/everolimus. The role of additional IO-based therapy in this setting is unproven, although there are data with lenvat...
What treatment options would you provide a HER2+/HR+ patient with significant residual disease s/p TCHP if they go on to develop severe neuropathy following adjuvant T-DM1 therapy?
We know from the KATHERINE study that invasive disease or death had occurred in 12.6% of the T-DM1 group and in 22.2% of the trastuzumab group. The estimated percentage of patients who were free of invasive disease at 3 years was 88.3% in the T-DM1 group and 77.0% in the trastuzumab group. However, ...
How do you counsel patients referred for abnormal light chain ratio when individual light chains are in normal range?
It appears you are referring to a situation where the uninvolved light chain is quite suppressed and the potentially involved light chain is normal, generating an abnormal ratio. There are other situations such as in CKD where both kappa and lambda light chains will be elevated but the ratio will be...