Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a symptomatic patient with with a history of whole brain RT with new bilateral MRI enhancing lesions within the optic nerves?
The differential would be optic neuritis from immunotherapy or leptomeningeal disease. Is there any visual deficit? It appears there is a lesion as described above rather than enhancement which would favor disease. One would need to know the disease status outside brain and if there is any other sus...
How would you treat a patient with newly diagnosed advanced urothelial cancer?
The current standard of front line systemic therapy for advanced urothelial cancer is cisplatin based combination chemotherapy: cisplatin/gemcitabine or ddMVAC, for cisplatin eligible patients. For cisplatin ineligible patients, pembrolizumab (Keynote 052), atezolizumab (IMvigor 210) or carboplatin/...
Do you recommend lenalidomide for high risk smoldering multiple myeloma?
If you want to push the can down the road that is a good approach. High risk SMM is more like early stage myeloma. Treating them with single agent does not make sense as we know that combination therapy and total therapy approach is superior. The ECOG study was perfect 15 years ago but not today.
How do you counsel patients with localized Ewing's sarcoma who wish to stop or cannot complete the full course of 14 cycles of perioperative chemotherapy?
Ewing sarcoma is sensitive to chemotherapy and studies over time have demonstrated survival benefit with dose intensification. If it can be tolerated with manageable toxicity, then I strongly encourage patients to complete the full course of chemotherapy when the goal of treatment is curative. Inter...
When would you consider metastastectomy of liver lesions in metastatic pancreatic cancer who achieve a favorable response to mFOLFIRINOX?
How would you approach a patient with early stage breast cancer on adjuvant docetaxel that developed lacrimal duct obstruction after 2 cycles?
If a patient has already developed one duct requiring stenting I would probably discontinue the docetaxel and substitute paclitaxel or nab-paclitaxel, which do not appear to have similar ocular toxicities. This is uncommon with q3wk administration of docetaxel but is drug-specific and your patient i...
Do you offer adjuvant chemotherapy to patients with urachal adenocarcinoma and at least one high risk feature?
In the absence of data in this space, I would offer adjuvant chemotherapy applying similar principles from colon adenocarcinoma for patients with T4 or node positive disease. FOLFOX/CAPOX for 3 to 6 months is reasonable in this situation. This regimen has the most reliable and reproducible data in t...
Do you routinely prescribe PCP prophylaxis for patients who will be on steroids long-term?
Yes. This is something I don't think is emphasized enough given the ease of the intervention and seriousness of infection. In my first year of practice, I saw 3 fatal cases of PCP in patients that were receiving steroids from medical oncology without PCP prophylaxis. So I prescribe it for virtually ...
How would you approach a patient with grade 1/2 pancreatic neuroendocrine tumor after progressing on octreotide?
Tem/cape -- responses are good for pancreatic NET. PRRT Is great but so expensive. I’m finding it so hard to get.
Do you ever start with lower than standard doses of TKIs when initiating treatment for chronic phase CML?
Not usually with the exception of bosutinib. I specifically start bosutinib at 200 mg and go up by 100 mg every week until the patient is at full dose. I find this helps manage the initial diarrhea associated with the drug. Otherwise, I start at the standard dose for all drugs. I may decrease the do...