Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In patients with a history of HIT, how do you counsel them on the use of the AstraZeneca vaccine given reports of unusual thrombosis and association with PF4/heparin antibodies?
Until we know more, it seems prudent to avoid the AstraZeneca and J&J vaccines, particularly if there is a history of HIT. The Pfizer and Moderna vaccines use a different technology and have not been associated with the thrombosis/thrombocytopenia syndrome.
When can defibrotide be discontinued before the 21-day treatment course is completed in a pediatric patient with SOS?
There is no data to support the 21-day use in everyone. Also, some patients might even need a longer course than the prescribed 21 days if manifestations are ongoing. A good general rule of thumb would be to continue (provided no bleeding or other toxicities) for 3-5-7 days post resolution of ong...
Do you offer maintenance rituximab in transplant ineligible patients with mantle cell lymphoma?
The data on the role of rituximab maintenance therapy in transplant ineligible patients with mantle cell lymphoma are not straightforward to interpret. The most often cited experience (Kluin-Nelemans, et al., PMID 22873532) is a complicated study with two randomizations: induction therapy was either...
What additional testing, if any, should be performed for an adolescent patient with heavy menstrual bleeding and a negative von Willebrand disease evaluation?
I presume that the adolescent with heavy menstrual bleeding whose von Willebrand panel is negative has already had a CBC and baseline coagulation screen (prothrombin time, activated partial thromboplastin time, and fibrinogen or thrombin time) performed. If that is the case, I would suggest evaluati...
Would you start TKI therapy in a patient with new diagnosis of T-ALL without BCR-ABL gene rearrangement on FISH but found to have very low level p190 transcript on RT-PCR?
I would not. I don't necessarily have any evidence to support this, so this is simply an opinion. I have seen this a couple of times in my clinical practice. If there is truly BCR-ABL present in this patient's leukemia, the level of it would have to be extremely low to only be detectable at this rep...
Do you routinely check platelet counts after COVID-19 vaccines in patients with chronic ITP?
Yes. the side effects of COVID vaccines are still evolving. Mild to moderate thrombocytopenia was noted and severe thrombocytopenia is extremely rare. I would follow an abundance of caution and do weekly complete blood counts, especially in the ITP patient.
Would you recommend use of ESA for anemia of kidney disease in the setting of metastatic solid tumor malignancy?
It is not unreasonable in CKD patients with symptomatic anemia and a non-curable metastatic cancer to consider using an ESA. However, this requires an extensive discussion with the patient. ASCO/ASH guidelines recommend against the use of these agents in patients with curable malignancies, so if the...
Is there a role for frontline combination therapy with a hypomethylating agent plus venetoclax for high risk MDS?
Yes, if we extrapolate from AML and based on promising phase 1b clinical trial results (link below) so far, but venetoclax is not approved for MDS as of yet. Improved CR but also increased cytopenias, dose has not been confirmed yet. https://www.ashclinicalnews.org/on-location/ash-annual-meeting/ven...
Do you routinely offer a bisphosphonate or denosumab to multiple myeloma patients without skeletal lesions?
Our practice is to give 2 years of bone-directed therapy in all comers. Preferably bisphosphonates over denosumab for cost reasons unless needed due to CKD or intolerance.I agree that the case is less compelling for patients without skeletal lesions at baseline. An old RCT of bisphosphonates versus ...
Would you consider allogeneic stem cell transplant for a newly diagnosed patient with favorable risk AML who had residual disease after initial therapy that included the need for re-induction?
Even though he/she is favorable risk, the fact that he/she required reinduction means biologically aggressive disease and hence increased risk of relapse. So would consider for allo sct. Also was the induction 7+3 or HIDAC induction? Did the patient go into CR after reinduction? What did the NGS sho...