Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider replacing ibrutinib with acalabrutinib or zanubrutinib in the TRIANGLE regimen for MCL in a patient with atrial fibrillation or high risk coronary syndromes who is otherwise fit for aggressive induction therapy?
Generally, if a patient is significantly symptomatic or intolerant due to atrial fibrillation, or other arrhythmia or even heart failure, it is reasonable to consider a next generation BTKI (acalabrutinib or zanubrutinib). As a cardiologist, I will defer to my cancer colleagues on efficacy across ad...
What post-protocol therapies did patients on the BRUIN trial in CLL receive, and how did these therapies impact outcomes?
The patients with CLL enrolled in the BRUIN study were heavily pre-treated with a median number of 3 prior therapies. All the patients in the BRUIN study had prior exposure to covalent BTK inhibitors and 40% of them also had been treated with a BCL2 inhibitor. As expected for patients offered a phas...
How would you consolidate a patient with primary refractory double hit lymphoma with secondary CNS involvement?
Thiotepa-based transplants are particularly rough. We haven't had good outcomes with them in terms of relapse and mortality is much higher than BEAM or Mel autos.Having said that, this patient has chemo-refractory disease. The initial concern with CAR-T in primary CNS or secondary involvement was th...
What post-protocol therapies did patients on the BRUIN trial in CLL receive, and how did these therapies impact outcomes?
The patients with CLL enrolled in the BRUIN study were heavily pre-treated with a median number of 3 prior therapies. All the patients in the BRUIN study had prior exposure to covalent BTK inhibitors and 40% of them also had been treated with a BCL2 inhibitor. As expected for patients offered a phas...
How would you consolidate a patient with primary refractory double hit lymphoma with secondary CNS involvement?
Thiotepa-based transplants are particularly rough. We haven't had good outcomes with them in terms of relapse and mortality is much higher than BEAM or Mel autos.Having said that, this patient has chemo-refractory disease. The initial concern with CAR-T in primary CNS or secondary involvement was th...
Do you routinely offer fungal prophylaxis for patients on BTK inhibitors?
We do not use antifungal prophylaxis for patients on BTK inhibitors. The risk of invasive fungal infection in patients treated with BTK inhibitors in recent large single institutional series have been 2 to 3%, without routine antifungal prophylaxis. The risk of fungal infection increases in patients...
Do you routinely offer fungal prophylaxis for patients on BTK inhibitors?
We do not use antifungal prophylaxis for patients on BTK inhibitors. The risk of invasive fungal infection in patients treated with BTK inhibitors in recent large single institutional series have been 2 to 3%, without routine antifungal prophylaxis. The risk of fungal infection increases in patients...
At what PSA level would you consider restaging a patient who was treated with ADT and radiation and had undetectable PSA?
The criteria for defining PSA relapse after radiation therapy remains the Phoenix criteria (see Roach et al., PMID 16798415), which is essentially nadir + a 2 point rise in serum PSA. Thus, a patient who achieves an undetectable PSA on ADT/RT but then experiences a PSA rise would not meet PSA relaps...
Do you routinely use higher-dose VTE prophylaxis in patients admitted with traumatic orthopedic injuries undergoing surgery?
Yes, at my institution, we have two separate order sets. One is for moderate-risk medicine patients, which recommends enoxaparin 30-40 mg daily depending on renal function (heparin for ESRD and low-weight patients). The other is for high-risk patients, which includes all orthopedic and trauma patien...
For patients with metastatic cancer on a systemic therapy regimen that includes bevacizumab, are you comfortable treating brain metastases (SRS or WBRT) without holding bevacizumab?
Multiple prospective trials have demonstrated the safety of combined bevacizumab and radiosurgery (from both recurrent GBM and brain mets) with some data to actually demonstrate a protective effect against radionecrosis. No significantly increased synergistic risk of intracranial bleed has been obse...