Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you decide on VRd vs DRd for initial management of transplant ineligible multiple myeloma?
Both VRd and DRd are reasonable induction regimens for newly diagnosed transplant ineligible patients. DRd has the most direct evidence, as there is a phase III study (MAIA, Facon et al., NEJM, 2019) comparing DRd to Rd with both arms including treatment until progression in a transplant ineligible ...
Are you routinely using thrombopoietin agonists in patients with hep C and HCC?
Thrombocytopenia is a common issue in patients with advanced liver disease due to decreased thrombopoietin production and hypersplenism sequestration from portal hypertension. The degree of thrombocytopenia is often a maker of both severity of liver disease.There are several TPO agonists on the mark...
How do you treat elderly or frail patients with metastatic RCC?
This is an important question as we enter the era of combination therapies in all risk categories, thus exposing patients to more side effects. I prefer to start with a single agent Checkpoint inhibitor with plans to escalate to combinations if there is disease progression. The OMNIVORE study and ot...
Would you consider using single agent oxaliplatin for adjuvant treatment for colon cancer in elderly patients who did not tolerate single agent 5-FU?
I would not recommend that. To my knowledge, there have not been any adjuvant studies addressing this question; but we know from at least 2 older RCTs, that oxaliplatin monotherapy has little or no meaningful efficacy in patients with advanced disease, despite earlier single-arm studies suggesting e...
How does your management change for patients with bone marrow failure due to a metastatic solid tumor to the marrow?
This is not an uncommon scenario in small cell lung cancer. Unfortunately, there are not much data to guide management, as most clinical trials exclude patients with abnormal counts. In this setting, I take the approach that if all other organ functions are acceptable, the bone marrow is unlikely to...
Does the use of slow release hormone replacement therapy impact your adjuvant treatment recommendations for a perimenopausal patient with an intermediate Oncotype score?
If she had a testosterone pellet this would not sway me to give chemo in someone who would otherwise get endocrine therapy alone. I would give the AI and monitor estradiol levels as the pellet wears off. Small studies of testosterone + anastrozole pellets didn't detect increased estradiol levels whe...
How do you approach the treatment for locally advanced gastric adenosquamous carcinoma following D2 resection?
As you suggested, there is a paucity of prospective data for gastric adenosquamous carcinomas (ASC). Some retrospective works (see Sci Rep 7, 4597 (2017)) have suggested higher T-stage, more nodal involvement, and worse prognosis, when compared to traditional adenocarcinomas. Whether or not this rep...
Is it reasonable to offer 3-days BEP regimen to a patient with high risk mixed germ cell tumor due to compliance issues?
There is data from an old EORTC study comparing standard 5 day BEP to 3 day courses. However, 3 caveats:1. Only for good risk disease2. More ototoxicity and probably more nauseaThe regimen has cisplatin 50mg/m2 x 2 and etoposide 165mg/ m2 x 3 as outlined here from the abstract:"A cycle of BEP consis...
How would you treat stage IV DLBCL with severe liver involvement?
I assume liver involvement with lymphoma has resulted in liver dysfunction and elevated bilirubin? If so, then I would use the direct bilirubin as a marker to dose adjust doxorubicin and vincristine. Elevated liver enzymes are not a reason to hold therapy in the absence of elevated bilirubin. Gener...
How do you treat metastatic testicular cancer with the primary orchiectomy pathology showing non-seminoma with components of teratoma and primitive neuroectodermal tumor?
If such a patient had evidence of widespread metastases with normal tumor markers, I would have the pathology on the orch specimen reviewed at an experienced center. Assuming that review confirms PNET component, I would consider systemic chemotherapy with alternating VIP/CAV. It is very unlikely to ...