Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In patients with breast cancer and concern for bone-only metastases on imaging but with non-diagnostic IR biopsies, do you pursue surgical bone resection for diagnosis or treat empirically for metastatic disease based on pathology from breast lesion?
The preferred approach would be to have confirmed tissue diagnosis and receptors repeated on the metastatic lesion, so if feasible/accessible, I would pursue that prior to treatment. If risks of biopsy outweigh benefits then treating empirically based on pathology from primary lesion sounds reasonab...
How would you approach a patient with high-grade gastric lymphoma who achieved a CR following chemotherapy?
About half of all lymphomas arising in the stomach are high-grade non-Hodgkin lymphomas, primarily DLBCL. Initial treatment would consist of chemoimmunotherapy (R-CHOP). The number of cycles of systemic therapy, and whether consolidation RT is appropriate, would depend upon stage, extent of disease ...
How do you prepare patients with DLBCL on the potential need for cellular therapies after progression on first line regimens?
Once a patient is identified by the lymphoma team, they are referred to our cellular therapy service for full evaluation and discussion of CAR T cell risks, benefits, and logistics. The discussion of protocol versus commercial product, chemotherapy side effects versus CRS/ICANS, and severity includi...
Would you consider adjuvant capecitabine in a patient with resected stage IA cholangiocarcinoma with MSI high status?
In general terms, I most likely would not recommend adjuvant capecitabine in a patient with completely resected, stage IA, mismatch-repair deficient cholangiocarcinoma. My justifications for this are as follows. First, the BILCAP study showed at best a marginal effectiveness of adjuvant capecitabine...
Would you add Daratumumab to upfront treatment of multiple myeloma in a patient with tetraploidy on FISH?
I think the shortest answer is, "Do what you do for your patients with high-risk cytogenetics." If you ask 4 different myeloma specialists, you'll get 4 different answers: VRd for everyone, Dara-VRd for everyone, KRd just for high-risk, Dara-KRd just for high-risk... and then some (not me) will reco...
How do you select systemic therapy for advanced HCC patients with portal vein thrombosis?
Generally, patients with advanced portal vein thrombosis (PVT) are excluded from studies, generally because it can impact the patient’s other hepatic indices. Extensive thrombosis may jeopardize blood flow in the liver, cause elevated bilirubin, reduced albumin, and increased ascites, i.e. lead to C...
Would you offer definitive local therapy to a patient with ER/PR+, Her2 neg breast cancer with oligometastatic disease that responded well to CDK 4/6 inhibitor +AI, despite NRG-BR002 results?
The description of "ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligo-metastatic disease in the right 4th rib (near primary tumor but not clearly direct extension) and good response to 6 months of AI+CDK4i" suggests that the primary breast cancer is intact. The...
Would you give palliative breast RT to a patient receiving weekly paclitaxel for rapidly progressing metastatic disease?
We would also feel comfortable using palliative RT since it can provide meaningful palliation. While the dose of taxol described is slightly higher than what we use during concurrent chemo/RT for lung cancer, the irradiated lung volumes will be far smaller in this setting, so we suspect this would b...
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...