Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What would be your approach to initial treatment of a patient with standard-risk myeloma unwilling to undergo autologous stem cell transplant, if practicing in a resource-limited setting?
For non-transplant candidates or patients unwilling to have transplant with standard risk MM, these are my 2 choices: RVd: len/velcade/dex: based on the SWOG S077 compared to Rd: Durie et al., PMID 28017406. Dara Rd: Daratumumab/Revlimid/dex: based on the MAIA study compared to Rd: Facon et al., PMI...
What is your recommended management algorithm for bleeding associated with an acquired factor VIII inhibitor?
Fragner et al., Cureus 2022.
How would you approach the treatment of cytopenia related to NK cell LGL leukemia?
You could use filgrastim and erythropoietin but I prefer to treat the underlying leukemia with low dose methotrexate or cytoxan. It may take up to 6 months to see responses to cytotoxic agents and you would need to support the patient during this time with transfusions or growth factors. Thrombocyto...
Would you discontinue anticoagulation in patients with antiphospholipid antibody syndrome, who have a remote history of thrombotic events and are now negative for pathogenic antiphospholipid antibodies?
I would certainly consider stopping anticoagulation in selected patients after an in-depth discussion about potential risks and benefits. I would not consider stopping AC in patients with a history of recurrent events, arterial events, or multiple risk factors for thrombosis (e.g. nephrotic syndrome...
Are there best practices or data regarding the use of open notes among oncology patients?
The 21st Century Cures Act regulation (effective April 2021) required that clinical notes such as consult and office notes be shared with patients, e.g. “open notes.” In general, surveys of patients with cancer and their clinicians suggest that open notes are viewed favorably (Salmi et al., PMID 330...
What radiation dose do you typically use for relapsed DLBCL following 6 cycles of R-CHOP?
There are several potential scenarios, all with different answers, so I will illustrate a few.Historically, second-line chemotherapy (e.g., R-ICE) would first be pursued for relapsed DLBCL, and if the disease was still responsive to chemotherapy (CR or PR), then the patient would proceed with high-d...
When and how do you initiate therapeutic phlebotomy for patients with hereditary hemochromatosis without evidence of end-organ injury?
Since the management of asymptomatic HH is seamless, if a patient's iron parameters are reflective of iron overload and there is zero evidence of end-organ damage, I recommend that they become blood donors, starting with every 56 days. I monitor on a regular basis to try to get them closer to low no...
What are your recommendations for a male patient who was recently started on imatinib and wants to conceive?
Great question. This comes up often. For males, they can continue to take their CML TKI and conceive a child. Of course, this is much more complicated for women as they should not be pregnant while taking a TKI. I would say that if the patient is having difficulties conceiving, he should undergo a ...
Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?
In this scenario, our patient with lupus is young and does not have features of APS. Nevertheless, any patient with Libman Sacks endocarditis carries a heightened risk for embolization. Regarding anticoagulation, the literature on this subject is anecdotal and conflicting with some authors recommend...
Would you recommend consolidative radiation therapy for advanced stage bulky Hodgkin's lymphoma with a delayed complete response after 6 cycles of A-AVD chemotherapy?
I suppose I have three comments about this question.First, the sensitivity (percentage of true positives) and specificity (percentage of true negatives) are generally higher than the positive predictive value (true positives/all positives) for end-of-treatment PET-CT in lymphoma. In one study, the P...