Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to pRBC transfusion support for myeloma-related anemia?
There is likely not a single right answer to this.The data suggests that a hemoglobin threshold of 7 g/dL is reasonable for critically ill patients rather than a higher threshold. The Clinical Practice Guidelines From the AABB recommend a threshold of 7-8 g/dL. In general, I follow these rules: Tran...
Is there a role for liver transplantation in an initially unresectable HCC with a complete response after bevacizumab-atezolizumab?
I have had one patient who successfully underwent liver transplantation after an excellent response to atezolizumab plus bevacizumab. The patient was young and otherwise healthy. Further, he was taken off treatment and had no recurrence after 2-3 months off immunotherapy before being considered for ...
Do you continue bortezomib past 8 cycles for transplant ineligible patients with multiple myeloma on VRd who are tolerating therapy well with no neuropathy?
Excellent question without a clear answer. While several RCTs have looked at post-induction maintenance among patients without planned transplantations, the British Myeloma XI trial is the biggest RCT (to my knowledge) to clearly look at lenalidomide vs observation in transplant-ineligible patients....
Do you offer consolidation durvalumab in stage III patients with NSCLC who developed grade 2 radiation pneumonitis during chemoradiation?
The cleanest answer is no, I would not put a patient on durvalumab who experienced pneumonitis during radiation. This is in keeping with the clinical protocol for the PACIFIC trial which excluded patients who experienced any grade pneumonitis during radiation (including grade 1). The reason we now o...
What is your preferred first line regimen for PDL1-negative squamous cell lung cancer?
Firstly, I think clinical trials, where available, should be considered for all patients particularly those with squamous and/or PD-L1 negative tumors as the benefits from chemo-IO in this setting have not been as striking as in PD-L1 positive or non squamous tumors, we have more work to do to impro...
When determining frontline treatment for NSCLC, would you incorporate molecular predictors of resistance to immunotherapy such as STK11, KEAP1, p53?
This is a great question and there are a number of first line trials that I hope will be able to answer this. I do believe that we should be evaluating these patients specifically for trials (i.e., NCT04265534). I also think looking at these data across the current studies including CM227 and 9LA wi...
Do you recommend COVID vaccination in patients with antiphospholipid antibody positivity or other prothrombotic states not on anti-coagulation?
There are hypothetical reasons that the COVID-19 vaccine might increase thrombophilia in individuals with APS/APLAs. However, the only controlled study I could find, Absence of hypercoagulability after nCoV-19 vaccination: An observational pilot study by Campello et al., PMID 34246010 did not show a...
Would you offer additional adjuvant FOLFOX for patients with rectal CA undergoing TNT who transition to cape/RT and subsequent surgery early due to absence of clinical response to FOLFOX?
Given the number of treatment approaches to rectal cancer, it remains one of our biggest challenges in terms of extrapolating from the larger evidence base in colon cancer.While the stage isn't given for the patient, let's assume they have a cT3N1 low rectal cancer and a TNT strategy is selected. If...
How would you manage VTE in a patient with bleeding disorder such as hemophilia?
Management of VTE in a patient with an inherited bleeding disorder depends on the specific disease, the severity of the bleeding disorder, and the past history of bleeding in that patient. In patients with serious past bleeding and low levels of factor, anticoagulants may be contraindicated and loca...
What factors do you take into account for recommending chemo/IO vs IO/IO vs CheckMate 9LA regimen in front line therapy for PD-L1 negative advanced squamous cell carcinoma?
As others have noted, the HR for the squamous subset of NSCLC seems to suggest that these patients benefit most from combined ICI, seen in both the CM227 and 9LA studies (with the caveat that comparator is chemotherapy alone which is now outdated.) In CM227, the HR for nivo-ipi vs chemo was 0.53 in ...