Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In the setting of platinum resistant ovarian cancer, do you consider repeat use of bevacizumab with subsequent lines of chemotherapy following prior treatment with chemotherapy + bevacizumab with bevacizumab maintenance?
I typically do reuse bevacizumab. Now that bevacizumab is approved for front-line, maintenance, and recurrent settings, many patients with recurrence may not be bev-naive, to begin with, and I still use bev+chemo.In breast cancer (von Minckwitz et al., PMID 25273342) and colon cancer (Bennouna et al...
Are there any situations where you would consider neoadjuvant chemoradiation as opposed to chemoimmunotherapy for patients with resectable NSCLC prior to surgical resection?
For most of the last 2 decades, there has been a raging debate about the best perioperative approach for the management of patients with high-risk resectable NSCLC, such as patients for example, with preop documented nodal disease. Clinical studies have not been able to settle the key questions whet...
What is your preferred first line regimen for myeloma with severe renal impairment, either on or off dialysis?
In general, for patients with renal insufficiency related to their myeloma, time is nephrons. So the earlier you can correct the hypercalcemia, lower circulating uric acid, stop ongoing bad behaviors (NSAID overuse, etc), and treat the myeloma, the better. If the patient is admitted, I will give pa...
Among non-HRRm castrate resistant prostate cancer patients, are there features predictive of response to PROPEL regimen of abiraterone/olaparib?
There is a theory that abiraterone can lead to changes in the tumor that could make it susceptible to PARP inhibitors. I understand that the clinical trial suggests that this may be the case, but I think we need more information as to whether or not this is actually happening.
In a patient with extensive stage small cell lung cancer and a neurologic paraneoplastic syndrome do you feel comfortable using an ICI along with the chemotherapy?
I have not used immune checkpoint inhibitors (ICI's) in patients with SCLC that have neurological paraneoplastic syndromes. These syndromes can be quite debilitating and given the risk of exacerbation of the symptoms by ICI use, I have not used them in this setting. One has to remember that the use ...
What criteria does your institution use to indicate patient is ready for PEG tube removal?
The short answer is we typically advise patients that if they can maintain an oral diet (using the tube for flushes only) for 2 weeks and demonstrate no weight loss they are typically ready for tube removal. Our patients though are followed through the course of their treatment by a dietician, and t...
Are there any differences in your approach to therapy for secondary versus primary myelofibrosis?
Good question. I will risk stratify patients with secondary MF using the MYSEC-PM score and primary MF patients using DIPSS+ or MIPSS. Anecdotally, patients with secondary MF tend to have more indolent MF and there is definitely a grey zone period when you know they are transforming but still doing ...
Is IL-6 inhibition an option in patients who are going to be rechallenged with checkpoint inhibitors after previously developing ICI-mediated temporal arteritis?
There are reports of using IL-6R inhibition in combination with checkpoint inhibitor therapy in other scenarios (e.g. inflammatory arthritis, cytokine release syndrome). So this would be a reasonable consideration if the oncologist feels strongly that further ICI therapy is beneficial.
Can you continue checkpoint inhibitor therapy in the setting of severe cutaneous irAE while concurrently treating the cutaneous reaction?
Cutaneous reactions from immune checkpoint inhibitors (ICPi) generally fit into 3 categories: rash/inflammatory dermatitis, bullous dermatoses, and severe cutaneous adverse reaction (SCAR). For grade 1-2 rash/inflammatory dermatitis, if symptoms can be managed with topical therapy or non-steroidal o...
Would the recent use of high dose glucocorticoids impact your selection of first-line therapy for patients with intermediate-poor risk metastatic RCC?
Definitely a common clinical scenario, unfortunately. Such patients often have poor risk highly symptomatic disease. In such symptomatic patients, we tend to prefer a VEGF/TKI-based regimen as first line therapy considering the relatively lower rate of primary progressive disease, higher objective r...