Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In a patient with history of recurrent VTE despite anticoagulation, would you consider lenalidomide as part of your initial myeloma regimen?
I would still consider lenalidomide as part of the initial myeloma regimen provided that they were on therapeutic dose anticoagulation (my preference is apixaban 5 mg BID or rivaroxaban 20 mg daily). Ideally, this would be started at least 3 months after therapeutic dose anticoagulation for the most...
How do you decide when, if ever, to defer pharmacologic venous thromboembolism prophylaxis for hospitalized patients?
For the majority of patients who are not actively bleeding, I use pharmacological prophylaxis. I prefer heparin products, unless they have a history of HIT or religious preferences on porcine products. Even for patients planned for surgery, heparin can always be held or reversed. I prefer LMWH over ...
Would you offer chemoRT to a colon cancer case with a resected polyp with positive margins if the patient wishes to avoid surgery?
“Wishes to avoid surgery” is different than refusing surgery. Subtle difference perhaps, but I feel like with proper counseling and persuasion, it is possible to “adjust” a wish. A hard refusal is a different matter. But be it wish or refusal, I would not irradiate. Think of how much normal tissue y...
In patients with active IBD and rectal cancer, do you take any precautions before starting TNT?
First, I would be sure that the patient really needs TNT. If a patient has active inflammatory bowel disease, they will not tolerate TNT very well. If a patient has inactive IBD, there is not likely to be much added morbidity. I would be very hesitant to use TNT if someone has really active IBD. The...
What could explain discordant iron studies?
This is an incredibly common question, largely generated by the zeal to use the serum ferritin and failure to appreciate the need for an overnight fast when ordering the TSAT (the ferritin does not require fasting). The most common culprit in this situation is iron containing vitamins. Prenatal vita...
At this time, how are you using MRD testing for clinical management of patients with multiple myeloma?
Off a clinical protocol, I only routinely use MRD (clonoSEQ) in a very specific setting. That setting is low risk patients who have received autologous transplant as part of first line therapy and did well. Specifically, if the patient's response to first line therapy is VGPR or better at day+60, th...
At this time, how are you using MRD testing for clinical management of patients with multiple myeloma?
Off a clinical protocol, I only routinely use MRD (clonoSEQ) in a very specific setting. That setting is low risk patients who have received autologous transplant as part of first line therapy and did well. Specifically, if the patient's response to first line therapy is VGPR or better at day+60, th...
What is your approach for adjuvant chemotherapy for a patient with colon adenocarcinoma, pMMR, T2 with 3 positive lymph nodes and 2 pericolic adipose tumor deposits?
This is a very timely question.The question is, should this patient be considered high-risk stage III even if this patient has a resected stage III colon cancer with pathology stage of pT2pN1b under the AJCC 8th edition? What is the prognostic value of tumor deposits (TD)?Tumor deposits (TD) in the ...
Would you consider omitting adjuvant durvalumab in MIBC to limit overtreatment in patients who may not benefit or those who have achieved maximal benefit after neoadjuvant gem/cis/durva?
The NIAGARA protocol included neoadjuvant durvalumab in combination cisplatin/gemcitabine, followed by adjuvant durvalumab regardless of the pathologic response at the time of surgery. Therefore, even those with pCR completed the year of adjuvant therapy. What is important to point out is that we do...
In which cases would you consider early transition to DOAC (within 72 hours) for hospitalized patients with intermediate or high risk PE?
Two DOACs are FDA-approved for early use (within 72 hrs), rivaroxaban and apixaban. The PEITHO-2 dabigatran cohort study included no comparison group (its authors called it a "trial"?) and required "72 hrs" parenteral anticoagulant before dabigatran but the small print in its Lancet Haematology show...