Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What regimen would you recommend for a younger, fit, transplant eligible patient with relapsed IDH1 positive AML?
If there was only one answer! The decision revolves around co-occurring cyto and molecular genetic abnormalities (in addition to IDH1) and the duration of remission in first CR. In general, IDH mutant AML - without other high-risk genetic lesions - is very responsive to all of our treatments whether...
With what agents can you replace PPIs if they cause thrombocytopenia?
The incidence of PPI-induced thrombocytopenia is very low - and really only reported in case reports. I would suggest ensuring the low platelet count is really from the PPI (in some cases may be reasonable to re-challenge the patient), and not from a more common reason. In a recent case report on La...
What would be your preferred second line treatment for a frail elderly patient progressing on Rd?
It will largely depend on the degree of frailty. Many of the myeloma therapeutics are well tolerated, even among older adults or those with comorbidities. Factors such as the time spent coming to clinic or to the infusion center matter as well. It is useful to understand the baseline cytogenetic abn...
Would you offer a complement inhibitor to a minimally symptomatic PNH patient with mild non-transfusion dependent hemolytic anemia?
The context would determine whether this patient should receive complement inhibitor. The first consideration is whether the patient has concurrent aplastic anemia or bone marrow failure. Often, patients with aplastic anemia have a small PNH clone that is not clinically significant and does not caus...
In which platelet function disorders would you consider use of Novoseven as opposed to platelet transfusion?
There are now two recombinant activated factor VII (rFVIIa) available in the US. Trade names are NovoSeven RT and SEVENFACT. NovoSeven RT is US FDA approved for use in Glanzmann thrombasthenia. There are case reports of its efficacy in off label use for other inherited platelet function defects. SEV...
Under what circumstances would you consider anticoagulation in a young female patient with persistently elevated factor XI activity?
First, get a baseline D-dimer to see how procoagulant she is at that point. If elevated, long travel on plane, pre-op and post-op for 2 months - consider short-term anticoagulation. If past thrombosis - give lifelong anticoagulation. If pregnant - follow D-dimer; if it goes up, anticoagulate.
Should patients with active multiple myeloma and other gammopathies be routinely vaccinated against herpes zoster?
All patients starting anti myeloma therapy should be on acyclovir prophylaxis, typically starting at 400 mg BID but renally adjusted to 400 mg daily if needed. This provides substantial protection against zoster. Patients may get shingrix but given that their immune response to the vaccine may be su...
How often should you repeat iron testing in patients with hemochromatosis, not on phlebotomy?
I can't think of a reason in the world to not do phlebotomy either therapeutically or through donation until TSAT is around 30 and ferritin is <100. I try to keep my hemochromatosis patients low, not high normal because the propensity for high TSATs makes subclinical deposition easy. I don't think t...
How do you approach treatment of vasculitis in a sickle cell disease patient?
Will highly depend on the vasculitis type and the acuity of the situation. For ANCA vasculitis, approaches based on rituximab and low glucocorticoid doses might be attractive (granted not severe disease, e.g. RPGN, DAH which should require pulse glucocorticoids). For large vessel vasculitis, a si...
Would you routinely use G-CSF prophylaxis in a CMML patient for decitabine-related neutropenia?
I would use G-CSF if the patient is in remission/responding to decitabine and neutropenia, is decitabine induced and not due to CMML. I will not use at diagnosis or when not in remission as neutropenia may be disease-related.