Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you use G-CSF for a patient with ALL admitted for febrile neutropenia with prolonged count recovery?
Acknowledging the lack of definitive data, in our group we use G-CSF as primary prophylaxis in adult patients with ALL treated with intensive chemotherapy and hardly ever need to re-administered if they develop FN subsequently. That said, for prolonged neutropenia despite prior G-CSF, we may adminis...
Do you commonly observe acute erythrocytosis in patients with ILD flares being treated with supplemental oxygen and high-dose corticosteroids?
Assuming that this patient does not have erythrocytosis at baseline, my experience is that acute erythrocytosis is not typical. Erythrocytosis caused by hypoxemia typically has a lag of several weeks, even though EPO increases within 48 hours. You commonly see a moderate acute leukocytosis with high...
What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?
I strongly advise against routine screening for monoclonal gammopathy in patients with thrombosis. The incidence of MGUS, particularly in older patients, is relatively high and so the signal-to-noise ratio in this setting will be very low. In a patient with recurrent thrombosis and thrombocytopenia ...
How do you manage high-risk MDS IB2 patients on HMA and venetoclax who develop an acute stroke requiring antiplatelet therapy?
Not sure of the current platelet count? Not sure of the age of the patient.Will still use antiplatelet therapy for acute stroke as advised.Support with platelet transfusion as needed for platelet count <20. Hopefully patient responds to HMA and venetoclax, and platelet counts improve.If in CR by mar...
How do you manage high-risk MDS IB2 patients on HMA and venetoclax who develop an acute stroke requiring antiplatelet therapy?
Not sure of the current platelet count? Not sure of the age of the patient.Will still use antiplatelet therapy for acute stroke as advised.Support with platelet transfusion as needed for platelet count <20. Hopefully patient responds to HMA and venetoclax, and platelet counts improve.If in CR by mar...
How would you manage aplastic anemia refractory to multiple agents?
If indeed the patient has been treated with all reasonable alternatives to BMT, the choices are 1) watch and wait with supportive care or 2) bone marrow transplantation. I understand the reluctance of transplanting someone in their 70s with aplastic anemia; however, we do this routinely in patients ...
Would you recommend 10 years instead of 5 years of tamoxifen in a premenopausal woman with early stage, node negative ER/PR/HER2 positive breast cancer?
Both the ATLAS and aTTom randomized controlled trials demonstrated that 10 years compared to 5 years of tamoxifen improves disease-free and overall survival among women with hormone receptor-positive early stage breast cancer. Most of the benefit was seen in the decrease in late breast cancer recurr...
How long do you give neoadjuvant therapy in resectable/borderline resectable pancreatic cancer, when you are considering chemoradiotherapy as part of your neoadjuvant strategy?
I would aim for at least 6 cycles. A recent large study from Mayo Clinic evaluated 194 patients with borderline resectable or locally advanced pancreatic adenocarcinoma treated with neoadjuvant chemotherapy followed by concurrent chemoradiation therapy. 94% of patients had an R0 resection.Only 3 fac...
What dose and formulation of GnRH agonist do you use for ovarian suppression in young breast cancer patients?
Available data is largely with the monthly formulation. I don't have a strong preference for which LHRH agent (though some payers might). The q12-week depot formulation may not maintain full suppression for younger patients. Here is my pragmatic strategy Start with monthly (q4 week). If not tolerat...
Would the presence of only mature teratoma on orchiectomy specimen lead you to consider upfront RPLND followed by adjuvant chemotherapy as opposed to upfront chemotherapy in a patient with bulky para-aortic nodal disease (cN3) and AFP/beta-HCG elevation?
If there is an elevated AFP or hCG, then by definition, he has metastatic germ cell cancer and needs chemo initially, followed almost certainly by post-chemo RPLND done by a skilled and experienced urologist.