Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients who have exceptionally long responses to HMA with high risk MDS or AML and not candidate for more aggressive therapy/transplant, do you consider treatment holidays or spacing out doses into longer intervals?
Over time, patients with MDS and/or AML on long-term HMA therapy tend to have lower counts, possibly due to less robust stem cell reserve. In general, we prefer to drop the dose (i.e. from 75mg/m2 to 50 mg/m2 for Azacitidine, from 20 mg/m2 to 10-15 mg/m2 for decitabine) as a first. In some patients,...
How do you treat a composite NHL of various subtypes?
There is no single answer here because composite lymphomas are highly varied and variable. The general principles here are to treat the component disease most in need of treatment, as best you can, and not to sacrifice curative intent for an aggressive curable component. For the case of composite ag...
What is your preferred maintenance therapy in young, fit patients with de novo plasma cell leukemia who achieve complete response after autologous stem cell transplantation?
Plasma cell leukemia is routinely excluded from post-transplant maintenance studies, so we cannot look to any of the randomized maintenance studies performed over the past decade. I would consider plasma cell leukemia to fit into the category of ultra-high risk myeloma, and would use lenalidomide pl...
Is there a role at this time for chemo-immunotherapy in the upfront treatment of classic Hodgkin lymphoma?
Would you require pre-RT dental evaluation and clearance for a patient who is being treated with ISRT to Waldeyer's ring/BOT area to 30 - 36Gy?
Yes. In the pre IMRT days, we certainly experienced some dryness and dental issues at dose of 30Gy, albeit much less severe than with typical carcinoma doses. With IMRT and salivary gland sparing the problem is clearly less, but it's hard to argue against a good dental evaluation pre RT. Talk with t...
What is the role of consolidative RT to initially bulky sites (>8cm) in a patient with stage III triple hit lymphoma who has tolerated only 4 cycles of DA-EPOCH-R?
I am going to expand the question to consider the role of RT in the curative rx of stage III/IV DLBCL triple hit or not. Conventional wisdom, e.g. NCCN guidelines suggest no role but I respectfully disagree. We reviewed the data in 2014 (Oncology 1074-1082, Dec 2014) and also recommend Dabaja et al ...
How do you decide to transition a patient with stable PNH on eculizumab to extended half-life ravulizumab?
It is not complicated to do the eculizumab->ravulizumab transition. When the next dose of eculizumab is due, I just substitute ravulizumab. The first one is the loading dose and 2 weeks later, the maintenance dose. Following the first maintenance dose, the schedule is every 8 weeks.
How would you approach treatment of DLBCL in a patient on hemodialysis?
For R- CHOP based therapy it can be administered the day before dialysis with no dose adjustments. Only Cyclophosphamide has renal clearance and should be reduced by 50%. For more aggressive regimens it becomes more challenging as there is not enough data. This is what we would consider doing for E...
Are you de-escalating treatment for favorable risk Stage I-II DLBCL patients to 4 cycles of R- CHOP with 2 additional rituximab cycles?
In general I could see this being an option in select patients (not localized stage II or patients who have a contraindication to XRT) but for the most part these patients in my practice are not treated with 6 cycles of R-CHOP. I treat most patients with Stage I and localized stage II with 3 cycles ...
What are the options of induction treatment of young AML patients who are on CRRT, continuous renal replacement therapy ?
Hypomethylating agent like decitabine and venetoclax will be good options. C1 decitabine for 10 days and venetoclax for 28 days. Then C2 decitabine for 5 days and venetoclax every 28 days. Bone marrow biopsy should be done on day 21. There is, however, no strong literature support regarding pharmaco...