Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you incorporate the ALASCCA trial into your clinical practice and perform NGS on all early stage colon cancer patients to determine if adjuvant aspirin would be beneficial?
Yes, I recommend obtaining PIK3CA testing on patients with resectable colon and rectal cancer based on the ALASCCA trial, as well as other data for patients who are able to receive low-dose aspirin if they have a PIK3CA mutation. NCCN guidelines currently recommend post-surgery/adjuvant therapy aspi...
How long would you anticoagulate for a catheter associated DVT in pregnancy?
Available guidelines for management of catheter-related DVT, including the 2012 ACCP CHEST guidelines, typically recommend 3 months of anticoagulation if the central venous catheter (CVC) is removed. In those who require ongoing CVC placement, which is common in patients with cancer requiring system...
How often do you check weight and adjust anticoagulation dosing in pregnancy?
In patients on prophylactic or intermediate doses of Lovenox (e.g., 1 mg/kg once daily), I do not adjust the dose during pregnancy. (Although this "intermediate-dose" approach is not supported by the Highlow trial, I will use 1 mg/kg daily in a woman with a more extensive clotting history—such as a ...
For patients with intermediate or lower risk essential thrombocythemia with plt >1000 but no symptoms, do you favor aspirin only therapy or aspirin and cytoreduction?
First, the wrong question is being asked. The correct question is, what is the proof that the low-risk, intermediate-risk, or high-risk ET classification has any validity? My answer would be that this classification has no validity. Whether it is based on the IPSET scoring system or one of the other...
Do you consider thrombocytopenia a contraindication for fibrinolytic therapy for a massive PE?
If one has access to mechanical thrombectomy devices and operators, they should be considered before systemic thrombolytics unless the massive PE is causing imminent danger to the patient/patient is going to code/die, in which case the risk of dying from said PE is higher than potential bleeding eve...
How do you determine the choice of therapy for platinum resistant ovarian cancer in healthy, good performance status patients?
Platinum-resistant epithelial ovarian cancer is generally defined as relapse less than 6 months following completion of primary or the last platinum-based chemotherapy regimen. Options for therapy include conventional, commercially available drugs or potential clinical trials. If prior genetic testi...
Would you consider adding immune checkpoint blockade to platinum + etoposide for metastatic high-grade large cell neuroendocrine tumor of the GI tract?
The addition of IO to first-line platinum/etoposide would primarily be an extrapolation of data from small cell lung cancer trials while awaiting the results of the ongoing SWOG 2012 trial being led by Dr. David Zhen (NCT05058651). We have hints of limited activity of single-agent checkpoint inhibit...
What is your second line therapy for PDL1 negative metastatic squamous esophageal cancer who did not receive a checkpoint inhibitor in first line setting?
I would not personally consider immunotherapy in any context for such a patient. For the purpose of answering this question, I assume that a "PD-L1 negative" tumor refers to a PD-L1 TPS 0% and CPS 0 tumor.As a quick reminder, the 2 relevant studies in the US for 1st-line immunotherapy in ESCC patien...
In patient with upper esophageal SCC who had partial response to neoadjuvant chemoradiation but deemed not to be a surgical candidate, would you recommend chemotherapy or nivolumab?
Once again, there's no clear answer to these head scratchers. For the purpose of answering this question, I will assume that the patient has a locally persistent tumor s/p definitive chemoradiation and is medically inoperable.In that case, the first issue to consider is whether there is a role for m...
What is your target Hgb/Hct for women who are pregnant and have sickle cell disease in whom you are doing scheduled transfusions?
Assuming that the patient is truly transfusion-dependent, the usual target range is a Hb of 9.5-10.5.