Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you stop hydroxyurea for thrombocytosis in a prostate patient receiving radiation?
In cervical cancer literature, when hydroxyurea was used with RT as a radiosensitizer, acute side effects were significantly increased, including myelosuppression. I would consider holding it during RT.
What is your approach to advanced Hodgkin Lymphoma when bleomycin is contraindicated and infectious complications arise with A-AVD?
This is a very good question and a bit complicated. In patients with advanced HL, for whom 6-8 cycles of treatment would be the typical course, I try to maximize the dose intensity and density even in the face of infectious complications. That said, if a patient is already receiving growth factor su...
Would you choose a different anti-CD20 antibody in early relapsed (< 6 months) DLBCL treated with rituximab?
Unfortunately, the largest clinical trial asking the same question you pose here—does substitution of the anti-CD20 antibody in combination with platinum-based chemotherapy in relapsed/refractory DLBCL following RCHOP improve outcomes—has failed to demonstrate benefit to such an approach. The ORCHAR...
Would you recommend prophylactic cranial irradiation (PCI) for a teenager with a T cell acute lymphoblastic leukemia in remission?
No—modern systemic and CNS directed therapy is sufficient to mitigate the historic higher risk of CNS relapse (Vora et al., JCO 2016). While there is still a small risk of cranial relapse with modern systemic therapy, the improved success of response and risk adapted strategies utilizing varying deg...
Would you anticoagulate a patient with an isolated arterial thrombosis in the setting of an inherited thrombophilia?
The situations in which anticoagulation is clearly required in cases of arterial thrombosis are: stroke or systemic embolism in association with atrial fibrillation or mechanical heart valves or presence of a mural thrombus (where anticoagulation with an appropriate agent should be administered prop...
How long after discontinuation of TKI (for complete remission) would you feel it is safe for a patient with CML to consider pregnancy?
Tyrosine kinase inhibitors have been demonstrated, in animal models, to be teratogenic when utilized early in pregnancy. In retrospective studies in humans, congenital anomalies similar to what was identified in animal studies have been reported. Since spermatogenesis takes several weeks, some have ...
What's your preferred management for a newly diagnosed chronic phase CML with concurrent thrombocytopenia?
It is unusual for patients with chronic phase CML to have thrombocytopenia as part of their initial diagnosis. I would first make sure the patient has chronic and not advanced phase CML at diagnosis by preforming a bone marrow biopsy. If the patient does have chronic phase CML, the choice of TKI is ...
Would you consider adding Enasidinib to frontline combination therapy with HMA and Venetoclax in a patient with newly diagnosed AML with IDH2 mutation that is >75 or unfit for standard induction therapy?
This question raises an important treatment consideration, but I would probably not use triple agents at this stage given lack of maturity of clinical trials. Venetoclax has been quite effective in those who have IDH1 and IDH2 mutations (Chan SM et al Nat Med 2015; 21:178), so I would probably start...
How do you approach the treatment of patients with an e14a3 (b3a3) BCR-ABL fusion in chronic phase CML?
The treatment is the same; the problem is how to monitor response as this rearrangement is detectable reliably by FISH and not by the typical RT-PCR. There is a report showing that CML with some rare fusion genes have a rapid response at early time points (3 and 6 months), but long term outcome seem...
How would you manage a patient with severe aplastic anemia and a large PNH clone?
This depends on many factors: What age at diagnosis, how big is the clone, hemolytic PNH? (LDH/Bili?), thrombosis? When did it develop (was it at diagnosis, or after IST), what is the marrow picture (hypo or hypercellular), what options for treatment are available, what HSCT protocols do you have at...