Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
What is the role of radiation therapy in recurrent Rosai-Dorfman disease after surgical resection, which manifests as many cutaneous lesions on the arms and buttocks?
I agree with Dr. @Dr. First Last. When I was in training, we reviewed the cases at MD Anderson. Radiation was only used for 9 patients (infrequently), and local control was achieved in 4 patients. So very small numbers, with uncertain benefits. Median RT dose 36 Gy. In the setting of multifocal dise...
How do you best incorporate use of filgrastim/pegfilgrastim in capecitabine based regimens?
Neutropenia during capecitabine is almost always a dose-related issue. Neutropenia can be thought of as a pharmacodynamic marker of drug exposure. If a patient is experiencing dose-limiting neutropenia during capecitabine-based therapy, they are likely receiving an excessive dose of one of the chemo...
How do you start and manage therapeutic SC heparin for acute thrombosis in pregnancy as the patient approaches delivery?
This is an excellent question and my approach to such a patient has changed over time. In my experience, therapeutic subcutaneous UFH is incredibly unpredictable--women may come in in labor on therapeutic UFH thinking that they will be able to get an epidural, but despite waiting hours and hours, th...
Do you offer patients with advanced endometrial cancer lower starting doses of lenvatinib when used in combination with pembrolizumab given high adverse event rates with 20 mg daily?
For the first part of the question, "Do you offer patients with advanced endometrial cancer lower starting doses of lenvatinib when used in combination with pembrolizumab given high adverse event rates with 20 mg daily?" The strategy of administering lenvatinib therapy by starting at the established...