Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to MRD testing in the frontline treatment of multiple myeloma?
Outside of clinical trials, I am not ordering MRD testing for patients in the newly diagnosed setting, regardless of transplant eligibility. While there are substantial data showing that MRD status correlates with survival outcomes (e.g., Munshi et al., Blood Adv 2020), there is a dearth of informat...
Would you consider post-BMT maintenance therapy for patients with Ph-like ALL with a JAK2 mutation?
In brief, I would not.Here is the evidence I have that leads to this conclusion: The activity of targeted therapy for Ph-like ALL has not been established. There are a number of ongoing studies that are attempting to address this (e.g., AALL1521/INCB18424-269; see Tasian et al., ASH 2022). What data...
Can you use apixaban or rivaroxaban in case of dabigatran failure?
It depends on the indication of anticoagulation, co-morbidities, etc. In the absence of any direct data, in general, failure in the setting of venous thrombosis or atrial fibrillation it would seem reasonable to consider transition to an agent with a different mechanism of action.
How do you manage grade 1-3A Follicle Center Lymphoma of the lower female genital tract, presenting with a cervical mass?
I would treat this with 12 x 2 Gy. Indeed, fertility preservation will be an issue here. Depending on the size of the lesion, if the ovaries can be spared, then 24 Gy delivered to the cervix/uterus may still allow for a pregnancy with a favorable outcome. Another experimental approach, if the patien...
What hemoglobin level prompts you to start erythropoietin in a patient with low-risk MDS?
Depending on the patient's symptoms and clinical context, I will either start an ESA when the patient starts becoming transfusion-dependent (Hgb < 8 g/dL) or, if the patient is not transfusion-dependent, but still symptomatic from anemia, I will start the ESA when their Hgb is < 10 g/dL. Prior to in...
How soon after CAR T-cell therapy can salvage radiation be delivered?
This is another important question. In our practice, the earliest we have treated patients is after their first post-CAR-T PET/CT at day 30. An abstract presented in an oral presentation at this year's ASTRO meeting by Dr. @Dr. First Last describes that radiation to sites of incomplete response at t...
Is there an optimal salvage radiation dose for relapsed post-CART disease?
While there is not enough data to definitively recommend a specific dose, we feel an EQD2 > 37.5-40 Gy is desirable for patients with limited residual or relapsed disease post-CAR T-cell. Our commonly recommended fractionations include 37.5 Gy in 15 fractions, 40 Gy in 15 fractions, and 40 Gy in 20 ...
Would you offer XRT as bridging for all patients with limited pre CAR-T disease or as consolidation for only those with residual PET-avidity on day+30 post CAR-T?
There are no studies comparing these 2 approaches. However, given the detrimental outcomes of post CAR-T relapses, I would consider maximizing peri-CAR-T treatments as much as possible as long as the toxicity profile is reasonable, and would not view these 2 approaches as mutually exclusive. I would...
Do you ever repeat screening for acquired von Willebrand in patients with essential thrombocythemia who have high platelet counts and very low risk disease not on cytoreductive therapy?
I generally check on a regular basis (i.e., yearly) to confirm no changes. Obviously, if there is bleeding I would check at that time.
How do you approach a persistently elevated mean platelet volume and immature platelet fraction in an otherwise healthy patient with a normal platelet count?
I am trying to understand the circumstances where this question might arise. Nowadays, when patients can readily see CBC results before their clinicians, they might notice the H or L designations and ask. In general, I would not think twice about "slightly out of range" CBC parameters in a single me...