Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage bruising in patients on ibrutinib?
Bruising is quite common in patients treated with ibrutinib, and it seems to be a class effect that also is seen with the 2nd generation BTK inhibitors, such as acalabrutinib. It should be mentioned when consenting patients, and reassurance generally is all that is needed because the bruising is usu...
Can acalabrutinib be used after ibrutinib failure in relapsed/refractory mantle cell lymphoma?
Acalabrutinib binds to the same pocket as ibrutinib on BTK. Theoretically, if a patient is ibrutinib resistant, acalabrutinib would not be effective. Ideally, there should have been a small trial testing this hypothesis. However, because of the theoretic concerns, nobody wants to do this trial. As w...
What are the factors that convince you to not immediately treat mantle cell lymphoma and to follow a course of "active surveillance"?
A subset of patients with MCL have a significantly longer survival (often more than 7-10 years) and a more indolent disease course. Two separate groups have reported patients who did not receive up-front chemotherapy at the time of diagnosis but were instead actively monitored, the watch-a...
What is your preferred BTK inhibitor for patients with relapsed/refractory mantle cell lymphoma?
The majority of patients with relapsed/refractory MCL will respond to single agent BTKi therapy and this is my preferred treatment in patients at first relapse when a clinical trial is not available, and they have not been exposed to a BTKi (for example, on a frontline clinical trial). I often used ...
When would you use acalabrutinib in combination with obinutuzumab vs acalabrutinib alone in upfront CLL treatment?
I generally prefer acalabrutinib for treating CLL.When this is first-line therapy and there is a need to give “fixed-duration" treatment, I use obinutuzumab + acalabrutinib. If this is a single agent (monotherapy), I use Acalabrutinib alone.For 2nd or 3rd line, if the patient previously has had chem...
What are the factors that convince you to not immediately treat mantle cell lymphoma and to follow a course of "active surveillance"?
A subset of patients with MCL have a significantly longer survival (often more than 7-10 years) and a more indolent disease course. Two separate groups have reported patients who did not receive up-front chemotherapy at the time of diagnosis but were instead actively monitored, the watch-a...
What is your preferred BTK inhibitor for patients with relapsed/refractory mantle cell lymphoma?
The majority of patients with relapsed/refractory MCL will respond to single agent BTKi therapy and this is my preferred treatment in patients at first relapse when a clinical trial is not available, and they have not been exposed to a BTKi (for example, on a frontline clinical trial). I often used ...
When would you use acalabrutinib in combination with obinutuzumab vs acalabrutinib alone in upfront CLL treatment?
I generally prefer acalabrutinib for treating CLL.When this is first-line therapy and there is a need to give “fixed-duration" treatment, I use obinutuzumab + acalabrutinib. If this is a single agent (monotherapy), I use Acalabrutinib alone.For 2nd or 3rd line, if the patient previously has had chem...
How would you treat a fit patient with a history of relapsed CLL who now presents with Richter transformation s/p autologous anti-CD19 chimeric antigen receptor (CAR) T-cells?
This is very challenging and essentially in a data-free zone. There are some data on off-label use of axi-cel for Richter, and liso-cel technically has a label for Richter. Results appear encouraging, but treatment and outcomes after CART failure are unknown. I would consider everything possible – c...
How would you treat a fit patient with a history of relapsed CLL who now presents with Richter transformation s/p autologous anti-CD19 chimeric antigen receptor (CAR) T-cells?
This is very challenging and essentially in a data-free zone. There are some data on off-label use of axi-cel for Richter, and liso-cel technically has a label for Richter. Results appear encouraging, but treatment and outcomes after CART failure are unknown. I would consider everything possible – c...