Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you treat metastatic HER2 positive breast cancer in a patient with hepatic visceral crisis?
I recently had a patient who presented with de novo HER2+ metastatic breast cancer and acute liver failure secondary to extensive liver metastasis. Her AST/ALT were > 5 times ULN and T. Bili was > 6. Docetaxel is not an option in this setting therefore, I opted to treat her with gemcitabine plus car...
In a patient with progressive thrombocytosis but negative MPN mutations on peripheral blood, what are your diagnostic and treatment recommendations?
I agree with Dr. @Dr. First Last. A bone marrow biopsy is helpful in a case like the one described as morphology can be informative in distinguishing triple negative ET vs pre-MF vs MF and also CML. I agree with NGS panel to see if there are clonal markers identified, testing for BCR-ABL is critical...
Would you move to a venetoclax-based regimen for a patient with pentarefractory MM and t(11;14) translocation, previously treated with bortezomib and carfilzomib?
To clarify what is meant by pentarefractory, we are referring to a situation where a patient's myeloma has proven resistant to two proteasome inhibitors (bortezomib, carfilzomib), two IMiDs (lenalidomide/pomalidomide), and an anti-CD38 monoclonal antibody (daratumumab/isatuximab). There are not many...
In a patient with HR B ALL and severe pancreatitis due to peg-asparaginase, how do you assess the impact of peg discontinuation on risk of relapse?
We know from Gupta et al., PMID 32275469 that omission of asparaginase courses from a mBFM chemotherapy backbone has an adverse prognostic impact among NCI HR patients. In fact, complete discontinuation of asparaginase was associated with a 50% increased risk of an event among HR patients. Thus, whe...
Would you add neoadjuvant pembrolizumab to chemotherapy in a premenopausal female with T2N1 breast cancer that is weakly ER or PR positive?
I would not give neoadjuvant pembrolizumab. Although cancers like the one described tend to behave more like triple negative cancers than hormone receptor positive ones, the KEYNOTE-522 study defined triple negative by the ASCO-CAP guidelines which (without knowing the details of this patient's path...
What data do you view as most impactful to treatment decisions in 1L metastatic ccRCC?
Certainly overall survival is the ultimate endpoint, but I would not discount PFS and complete responses (CRs do drive survival benefit in a small subset of patients as evidenced by high dose IL-2). Currently we have no data comparing IO/IO vs IO/TKI combinations head to head, so we generally select...
Would you use pembrolizumab to treat patients with BCG-refractory Ta or T1 NMIBC without CIS?
Pembrolizumab FDA-approved indication includes BCG-unresponsive CIS with or without papillary tumor in patients who refuse or cannot undergo radical cystectomy based on the cohort A of KEYNOTE-057 trial. The question of data extrapolation to BCG-unresponsive Ta or T1 without CIS is a reasonable one....
How do you approach the initial dosing of carfilzomib for patients with relapsed multiple myeloma?
A great question and one without a uniform answer! I place a lot of focus on patient quality of life, and one of the recurring themes from patients is the number of visits to the medical center. A twice-weekly regimen of carfilzomib (or bortezomib for that matter), over the course of a year, results...
How would you manage a patient with acquired von Willebrand disease who requires DAPT for arterial disease?
Acquired vWF has many causes: lymphoproliferative disorders; MPN; autoimmune disorders; high flow disorders (Heyde syndrome) and drugs. Treating the underlying disorders would be the safest strategy because DAPT is going to cause bleeding per se in some patients and removing a second cause for bleed...
In the absence of symptoms would you still treat high risk myelofibrosis if transplant ineligible?
If a patient with high risk PMF is not a transplant candidate, any therapy is, by definition, palliative and in the absence of symptoms, the potential risks of therapy would theoretically outweigh its benefits (e.g., anemia, leukopenia, or thrombocytopenia). The presence of asymptomatic leukocytosis...