Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you use bevacizumab in patients with history of VTE (DVT/PE) who are stable on anticoagulation?
I have used bevacizumab in many patients who are stable on therapeutic anticoagulation for prior VTE. If the first VTE occurs during treatment with bevacizumab, I hold the drug and then consider restarting it (if warranted by the clinical situation) after a period of stability on therapeutic anticoa...
How do you choose among regimens for relapsed refractory myeloma?
To be brief - no one chooses elotuzumab with no single agent activity if Daratumumab is available, with its approximate 30% response rate in its pivotal study. I was just sitting down at a meeting with a number of myeloma physicians asking how do we currently choose treatment for relapsed myeloma.Fo...
For Hodgkin lymphoma patients with initial splenic involvement, do you ever include the pre-chemotherapy involved spleen as part of your consolidative ISRT treatment after a CR?
Our long standing policy, first at Yale, for the last 3 decades at Duke, has been to use consolidation RT to all sites of disease known to be present prior to chemotherapy, irrespective of "bulk". On a log scale little difference between bulk and clinically detectable disease of any size. The origin...
When do you consider re-starting treatment for a patient with relapsed myeloma?
Do you start anti-myeloma therapy when patients have progressive disease (25% increase in paraprotein or new or worsening myeloma bone disease) or clinical relapse (CRAB criteria, hyperviscosity, new plasmacytoma)? The goal is to pull the trigger right before clinical relapse. How is this done in th...
Do you prefer a chemo-radiation combination or chemotherapy followed by sequential radiation approach for early stage NK/T-cell lymphoma?
If SMILE regimen is used here (the preferred regimen for NK/Tcell lymphoma), radiotherapy should be delivered sequentially (not concurrent) due to normal tissue toxicity and poor tolerance.
When do you choose to give CyBorD over RVd in a newly diagnosed myeloma patient?
I only use VCd when patients are going to be inpatient for a while or the patient is unable to afford an IMiD. For patients with renal insufficiency, where time is of the essence, I recommend Velcade 1.3 mg/m2 SQ days 1,4,8,11 + dex 20 mg days 1,4,8,11 with Revlimid 5-15 mg in newly diagnosed MM. L...
How would you treat a fit, newly diagnosed, high-risk multiple myeloma patient with multiple poor risk factors and circulating plasma cells?
So...on most iFISH, we see a deletion of p53, but we don't know about the mutation. Similarly on iFISH we see trisomies and tetrasomies of 1q23, often CKS1B, but not genetic amplification. Finally circulating plasma cells are often missed when less than 5% even at large academic centers, and while t...
Would you use alternative management in a chronic phase CML with a 3 way translocation between chromosome 9, 22 and 7?
Variant Philadelphia chromosome translocations that involve a third or fourth chromosome in addition to chromosomes 9 and 22 are seen in around 5% of patients with CML. They are considered simple translocations if involved chromosome 22 in addition to a chromosome other than 9, or complex if involve...
How do you approach small lymphocytic lymphoma that does not have a leukemic phase?
Patients with SLL very often (90-95%) have circulating tumor cells in the blood that are CD19, CD20, CD5, CD23, sig dim by flow consistent with CLL tumor cells. If not in the blood, these same cells evevn more often can be found in the bone marrow. If disease is in either site with nodal involvement...
What would you choose as a first line therapy for a patient with CLL who is asymptomatic with Rai Stage 4 with bulky adenopathy and organomegaly?
A big discriminating feature here would be based upon age. For a patient who is fit and <65-70 years, IGHV mutated disease may be curable with fludarabine, cyclophosphamde, and rituximab therapy, first piloted by Michael Keating's group at MD Anderson Cancer Center. At a median follow up time period...