Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
What is your preferred approach to adjuvant therapy for a Masaoka Stage III thymic carcinoma after R1 resection?
The data for adjuvant treatment of thymic carcinoma is relatively scarce, with most studies and series on this topic have traditionally included all thymic malignancies including thymomas. In the scenario presented in the question, there are multiple risk factors- thymic carcinoma, R1 resection both...
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...
Would you treat iron deficiency in post PV myelofibrosis if anemia is the predominant concern?
Absolutely would treat with IV iron. I have discussed this with KOL's and there is unanimity. You may buy a protracted period with anemia control. Not giving it is ill-considered. Where there is disagreement, is in the P Vera patient in excellent control, not anemic but with symptomatic iron deficie...