Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer adjuvant chemotherapy to a young adult with undifferentiated embryonal sarcoma of the liver?
This is an "ultra" rare and interesting entity, predominantly seen in the pediatric population, but I have seen a few in adults. This should not be confused with embryonal RMS - totally different entity. Clearly there is no data, and there will never be any data to support an evidence-based recommen...
Is there an absolute IgM level, in an asymptomatic patient on surveillance that initiation of therapy would be considered for Waldenstrom's macroglobulinemia?
The rate of progression of a paraprotein in a plasma cell disorder or LPL is always concerning, but it's not enough to bring about action. That said, we clinicians are always looking for bad behavior by cancer cells -- these are the indications for treatment more than the rate of rise or attainment ...
For a patient with MM progressing on a daratumumab-based regimen, is it preferable to entirely switch drug class or is another monoclonal antibody such as isatuximab an acceptable next step?
Class switch approach appears to give better disease control, isatuximab does not have activity in daratumumab refractory patients (Mikhael et al., PMID 33980831).
Would you recommend adjuvant tamoxifen in premenopausal woman with high grade DCIS and familial CHEK2 mutation who had bilateral mastectomies?
While risk of CBC is higher in women with known PV in CHEK 2 1100delC (Kriege et al., PMID 24918820), bilateral mastectomies offers the greatest risk reduction for this premenopausal woman with high grade DCIS and pathogenic germline CHEK2 mutation. Results from CPM in high risk individuals consiste...
What is the role, if any, for next generation sequencing testing in patients with suspected MPN who test negative for commonly identified mutations such as JAK2, CALR, MPL, and BCR-ABL?
This is a very relevant question and one that comes up often as NGS testing has become widely available. First, it's important to remember that not all abnormal blood counts, high in particular = MPN or malignancy. This is especially true in patients with erythrocytosis as the vast majority of PV pa...
How often do you monitor thiamine levels in a myelofibrosis patient taking fedratinib?
I give all my patients Thiamine and therefore, I do not routinely monitor thiamine levels in patients on fedratinib. I will occasionally check levels prior to starting.
Do you consider splenic response as adequate to judge efficacy of JAK2 inhibitors in myeloproliferative disorders?
It is the basis for regulatory approval for JAKi, and it is a clear measure of efficacy as it is associated with better clinical outcomes and improved QoL. However, it is not the end-all, be-all for endpoints. As we design studies to test new therapies, we need to move beyond SVR and TSS50 to endpoi...
How would you approach chronic isolated severe non-cyclic neutropenia with negative bone marrow and rheumatologic work-up?
My preference would be to use G-CSF at the lowest effective dose, i.e., the dose that maintains the ANC >1000. The risk of inducing leukemia is low in individuals with idiopathic, chronic neutropenia, but it is positively correlated with the G-CSF dose. There are also other side effects like bone pa...
Do you routinely monitor CEA in addition to CA 19-9 in patients with pancreatic cancer?
Yes. All patients are monitored serially with CEA and CA 19.9. If bilirubin is elevated due to obstruction rather than hepatic metastases, CA 19.9 elevation relates to obstruction rather than cancer status. In patients who do not have elevated CEA or CA 19.9 on presentation, we utilize ctDNA as a ma...
How do you manage cancer treatment-related cognitive change or "chemo brain?"
Chemo-brain is a vexing and complicated diagnosis. In most cases, you don't know the baseline neurocognitive function of individuals with cancer. Many conditions that are associated with chemotherapy like fatigue, depression, and aging can mimic chemo-brain. Estimates are that about 20% of individua...