Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you consider discontinuing brentuximab in stage III-IV classical Hodgkin lymphoma patients on AVD+brentuximab who have a good response to 2 cycles?
Now that the 4 year progression free survival results are available (Bartlett, 2019 ASH abstracts, #4026: 4-y PFS A-AVD 82%, ABVD 75%), the evidence for superiority of A-AVD is clear. This better outcome with A-AVD was achieved when the brentuximab was kept included through all 6 cycles of chemother...
How do you manage patients who develop de novo or recurrent skin cancers (SCC or BCC) while on lenalidomide?
The most common hematologic malignancies in patients who have undergone stem cell transplantation and then lenalidomide maintenance are acute myeloid leukemia, myelodysplastic syndrome, and rarely acute lymphocytic leukemia (Palumbo A, Lancet Oncol, 2014, PMID 24525202 & Aldoss I, Leukemia, 2019).Le...
What is the preferred approach for giving high dose methotrexate in double or triple hit lymphomas being treated with dA-EPOCH-R?
I do not usually offer HD IV methotrexate for DHL without documented CNS disease. Instead, I use 4 cycles of IT methotrexate in addition to DA R-EPOCH (Blood 2017). For patients with documented CNS involvement, you can place an Ommaya reservoir for an intensive intrathecal therapy and I recommend us...
What would you recommend for a stage I follicular lymphoma of the bone?
Definitive treatment would be 24 Gy/12 to area of disease with margin (not entire bone). See ILROG guidelines for extranodal lymphoma (Yahalom et al., PMID 25863750).
Would you forgo consolidation radiotherapy for a patient with stage 1EA diffuse large B cell lymphoma of the stomach who presented with a perforated ulcer?
Good Question! Based on recently published SWOG 1001 (Persky et al., PMID 32658627), patients can be treated for stage I/II DLBCL with RCHOPx3. If iPET is negative at that time, one more cycle of RCHOP and no RT yields excellent outcomes (5 year PFS = 87%). This is the new standard of care. Having s...
Do you have preferred regimens for young patients (<30 y/o) with early stage DLBCL?
For patients with early-stage, non-bulky disease, 3 cycles of R-CHOP + ISRT (30 Gy) provides excellent outcomes. This strategy is particularly attractive if the site(s) of disease requiring irradiation would engender a very low risk of late effects from RT (e.g., an inguinal lymph node). In the rand...
Would you consider splenectomy for an early stage l/ll primary splenic diffuse large B cell lymphoma followed by R-CHOP?
No reason to remove the spleen in most cases unless it was removed to secure the diagnosis. In this case, I assume the spleen was biopsied already? I would treat as you would a stage I DLBCL (the spleen is nodal tissue), but consider 6 cycles of R-CHOP if possible. If CR by PET at the end of treatme...
Would you consider giving ESA for anemia secondary to chronic kidney disease in a patient with follicular lymphoma in remission and on rituximab maintenance?
Yes. The risk of ESA has been re-evaluated and is not considered a risk of NHL. Even with the prior retrospective data, follicular lymphoma is not a curable disease and therefore ESA would not have been contraindicated.
How do you determine whether to treat a young adult with stage IA Hodgkin Lymphoma with the adult or pediatric treatment paradigm?
There is a long history of pediatric protocols for HL differing somewhat from the adult ones, but not much biologic rationale to support this, as the disease in young adults is biologically the same as in pediatric patients. Side effects of RX may of course differ, particularly with regards to RT an...
Should patients with bleeding disorders increase their home supplies of clotting factors foreseeing a possible shortage of product availability due to COVID-19?
No. The Medical and Scientific Advisory Council (MASAC) for the World Federation of Hemophilia recommends against increasing the already recommended home supply of clotting factors: One month worth of regular prophylaxis doses if on a prophylactic regimen; and one major correction dose, and two mino...