Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
Do you prefer hyper-CVAD or the CALGB 9111 protocol for high intensity remission induction treatment in Ph-negative ALL patients?
It depends on the patient's age. Historically, the adolescents and young adults (AYAs) population, arbitrarily defined by the National Cancer Institute as those between the ages of 15 to 39 years old, had worse outcomes compared to children with B-ALL (EFS of 30-40%). This is largely driven by adver...
What therapy do you usually choose in patients with previously treated follicular lymphoma who experience early relapse (< 2 years)?
My approach to POD24 patients is to first ensure there is no evidence of transformed disease. According to a retrospective analysis led by @Dr. First Last at Memorial Sloan Kettering, as many as 40% of the POD24 patients have evidence of transformed disease if a biopsy is pursued. Clinical indicator...
What is your approach to a patient with systemic AL amyloidosis who has achieved a hematologic response but not an organ response with CyBorD?
I would leave them alone. Treating to organ response is wrong and dangerous. Hematologic response is quick, organ response is delayed. The goal is hematologic remission; after that allow the body the time needed to heal the organs.
What is your approach in a transplant-eligible patient with relapsed classical Hodgkin lymphoma who has an area of refractory disease after salvage chemotherapy?
The goal here, especially in Hodgkin's lymphoma, is to achieve complete metabolic remission (CMR) by PET before high dose chemotherapy and autoSCT as data is clear in terms of difference in the outcome in favor of patients achieving CMR vs. those who achieved < CMR. So I would do what it takes to ac...
Do you recommend lenalidomide for high risk smoldering multiple myeloma?
If you want to push the can down the road that is a good approach. High risk SMM is more like early stage myeloma. Treating them with single agent does not make sense as we know that combination therapy and total therapy approach is superior. The ECOG study was perfect 15 years ago but not today.