Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage a transplant-eligible patient with DLBCL who relapsed 6-12 months following a CR1 to R-CHOP and then attained a CR2 to platinum-based salvage chemoimmunotherapy?
In this case, given that the patient obtained a CR2 to salvage therapy, I would, if they are otherwise eligible, take this patient to transplant given the data presented by Shadman et al., PMID 34570879 which indicates that those with at least a PR from salvage chemotherapy appeared to benefit as mu...
Would you continue warfarin anticoagulation in patients with unprovoked DVT if switching to low-dose DOAC is cost-prohibitive?
If switching to low dose DOAC is an option then could switching to ASA 81 also be an option? If not, I would continue warfarin as long as the patient has been able to maintain a therapeutic INR. I would not lower the INR range.
How can oncologists be more collaborative with palliative care physicians?
First and foremost, for oncologists to be collaborative with palliative care physicians, a trusting relationship is a must (good communication amongst teams is key to optimal patient care). This is akin to PCP-Oncologist (or even PCP-any other specialist relationship). Before advances in science and...
Would you consider complement inhibitor therapy or immunosuppressive therapy (e.g. cyclosporine, corticosteroids) for a patient with a PNH clone and early MDS who presents with pancytopenia?
It would depend on the size of the PNH clone and whether or not it was the dominant process as suggested by the depth of the cytopenias and whether there is evidence of hemolysis. I've seen a number of patients with MDS who are concurrently diagnosed with a small PNH clone and I have directed my tre...
How would you manage a patient with CML in chronic phase with a significant cardiac history, such as heart failure with reduced ejection fraction or arrhythmia?
The management of a patient with Chronic Myeloid Leukemia (CML) in the chronic phase who also has a significant cardiac history, such as heart failure with reduced ejection fraction (HFrEF) or arrhythmia, involves a multidisciplinary approach that includes both hematologic and cardiac care (cardio-o...
What is your ferritin threshold to prescribe iron to female adolescent athletes who have symptomatic iron deficiency without anemia?
Since ferritin should be truly reflective of iron levels as we should not expect elevated hepcidin levels in a young athlete. There, I would use 30 ng/mL which has a 98% specificity and 92% sensitivity for absent marrow hemosiderin. Also, since there is expected ongoing iron loss (0.6 mg/L of sweat ...
Would you anticoagulate a patient with an asymptomatic gonadal vein thrombosis on CT scan, found on surveillance imaging for colorectal cancer?
This is an area for which there are very limited reports (case reports/series) and certainly no small or large prospective studies. My bias is to initiate anticoagulation. It would be very important to look for an underlying malignancy or other explanation for the thrombus.
Would you consider radiation therapy before chemotherapy in a patient with stage I-II high-grade B-cell lymphoma presenting with a large necrotic skin lesion?
I would add that it is important to have a reasonable overall plan with Heme-Onc agreed upon to increase the likelihood of a successful outcome. Ideally, chemotherapy is administered first. This allows "consolidation" RT to be customized based on response. For example, a lower dose is utilized in a ...
If blood counts are being checked during concurrent chemoradiation, is there a number at which point you would recommend a radiation treatment break?
I’ll let the platelets go as low as 10K before stopping. I lean heavily on the rate of decline to intervene with a break sooner than the absolute numbers if heading for trouble and later if decline is slow and at reaching the end of treatment.
Is there a role for rituximab in refractory HIT?
If the patient has continued thrombosis/thrombocytopenia after the withdrawal of heparin, the patient could be considered to have autoimmune HIT as described in this excellent article by Warkentin, PMID 37959386.There are case reports of the use of rituximab for refractory HIT. Batra et al., ASH Abs...