Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Does the presence of osteoporosis change the extent of workup that should be performed for an older patient with otherwise serologically low-risk MGUS?
In brief - no, it shouldn't. While some previous studies have suggested that patients with MGUS are more likely to develop osteoporosis than those who don't, this is often related to confounders when MGUS is picked up clinically - in other words, patients with comorbidities that prompt a doctor to l...
Does the presence of osteoporosis change the extent of workup that should be performed for an older patient with otherwise serologically low-risk MGUS?
In brief - no, it shouldn't. While some previous studies have suggested that patients with MGUS are more likely to develop osteoporosis than those who don't, this is often related to confounders when MGUS is picked up clinically - in other words, patients with comorbidities that prompt a doctor to l...
How do you determine when to use a maintenance regimen vs continuous 3-drug regimen in a transplant-ineligible MM patient after response to first line therapy?
After completing initial therapy (which may or may not include high dose melphalan and auto SCT), I typically use maintenance lenalidomide. I consider “dual maintenance,” which is combining lenalidomide and a proteasome inhibitor, for patients with high risk FISH: t(4;14), t(14;16), and del17p. 1q g...
How do you determine when to use a maintenance regimen vs continuous 3-drug regimen in a transplant-ineligible MM patient after response to first line therapy?
After completing initial therapy (which may or may not include high dose melphalan and auto SCT), I typically use maintenance lenalidomide. I consider “dual maintenance,” which is combining lenalidomide and a proteasome inhibitor, for patients with high risk FISH: t(4;14), t(14;16), and del17p. 1q g...
For patients with multiple myeloma, when using Lenalidomide or Pomalidomide, how do you approach dose adjustment based on patient tolerance?
In general, my approach is to try to keep patients on the intended dose of an IMiD for as long as they can tolerate it (within reason). I think early dose reductions can be avoided by dedicated supportive care. For rashes, using antihistamines and topical corticosteroids can help. For diarrhea, imod...
How do you manage insomnia in cancer patients that is refractory to traditional sleep aides?
Insomnia and other sleep disturbances are very common in individuals diagnosed with cancer, and it is often helpful for patients to hear this. A good history of other contributors to sleep disturbance can be helpful as well. Often, depression, anxiety, and pain, as well as other stimulant medication...
What is the anticoagulation recommendation for a chronic DVT?
Simply having a chronic DVT is not an indication for anticoagulation. In general, acute provoked VTE requires a minimum of 3 months of anticoagulation. For an unprovoked VTE, there are scoring systems that guide towards limited duration vs long-term of anticoagulation. So it depends on where the fin...
How do you incorporate blinatumomab into therapy for a pediatric or AYA patient with isolated CNS relapse of B-ALL, if at all?
I try to prioritize CAR-T in this setting. Getting there depends on logistics such as financial clearance/collection though. If late relapse or if there is a delay in getting CAR-T, would treat with AALL1331 Arm D (with XRT in mtn), substituting block 3 of blina for block 3 on Arm C (to get more CNS...
How would you approach first-line treatment in metastatic NSCLC for a patient with ALK-EML4 V3a/b variant and MSI-high status?
It's a good question. I would first confirm the MSI-high status using tissue-based testing. I would recommend a pathology re-review in light of these molecular findings, and consider the possibility that this could be metastatic colorectal cancer. While EML4-ALK fusions are most common in NSCLC, the...
If a patient with non-metastatic prostate cancer is found to have a BRCA mutation, should this influence treatment recommendations for local therapy?
While there are no randomized trials to address this question, one prospective, non-randomized study of BRCA2 carriers with localized prostate cancer suggested improved outcomes with lower relapse rates in men treated with radical prostatectomy as opposed to radiation therapy. See: Castro et al., Jo...