Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach patients with AL amyloidosis with t(11;14) who have not achieved a hematologic complete response to induction therapy with 6 cycles of Dara-CyBorD?
Achieving an early hem deep response (at least VGPR or better) is crucial for organ response and has demonstrated OS benefit.I would favor changing treatment even by cycle 4 if the hematologic response is <PR. Early switch in such situations led to improved EFS and better chances for an organ respon...
How would you manage elevated vWF and FVIII levels in a patient with a family history of coagulopathy?
Hard to be specific without more clinical details. I would not repeat levels. Although the higher the FVIII and VWF levels, the higher the risk of thrombosis, but there is no known specific cut-off. Currently, there is no role for empiric anticoagulation. As with all patients, DVT prophylaxis in hig...
When, if ever, do you consider administering weekly paclitaxel prior to dose dense AC for neoadjuvant treatment of breast cancer?
There are data that the sequence of initiating neoadjuvant chemotherapy with a taxane prior to an anthracycline may result in greater reduction of circulating breast cancer cells (Pachmann 2004 - page S224). In the small randomized NeoSAMBA trial, T-FAC had improved clinical outcomes, such as DFS, c...
How would you manage BCR-ABL CML that is resistant to imatinib, with concurrent JAK2 mutation?
As Dr. Tremblay mentioned, it’s important to separate the JAK2 component from CML. If the patient truly has a JAK2 mutant MPN, I would treat it depending on what the manifestations of that disease are. On the CML front, I would manage the imatinib resistance the same way you would any other patient....
How would you manage BCR-ABL CML that is resistant to imatinib, with concurrent JAK2 mutation?
As Dr. Tremblay mentioned, it’s important to separate the JAK2 component from CML. If the patient truly has a JAK2 mutant MPN, I would treat it depending on what the manifestations of that disease are. On the CML front, I would manage the imatinib resistance the same way you would any other patient....
How would you manage superficial vein thrombosis that persists on imaging after treatment with full dose anticoagulation?
This is a challenging yet instructive real-life case in clinical decision-making, highlighting variations in practice that often diverge from existing evidence.Before answering let me make some assumptions: Duplex Ultrasound Findings: I assume that Duplex ultrasound did not reveal thrombus extension...
What is your current practice for de-escalation of frequency of administration of bispecific antibodies among responders in patients with relapsed/refractory multiple myeloma?
This is a great question. Since the majority of patients respond, I'm not clear of the PFS benefit derived from maintaining dose intensity in patients with ≤ partial response. The majority of the data regarding de-escalation is from single-arm or registration trials that were not designed to discove...
How would you treat a patient with rectal cancer with a solitary lung metastasis, who now has no evidence of disease after total neoadjuvant therapy followed by rectal surgery and resection of the solitary metastasis?
Surveillance! Assuming this patient received “complete” total neoadjuvant therapy with at least 3-4 months of systemic therapy, preoperative radiotherapy to the pelvis and curative intent operations to the pelvis and lung with no evidence of residual disease on post-op imaging- this is the early out...
Does a negative staging PSMA PET in a patient with biopsy-proven recurrent prostatic adenocarcinoma change your management?
The bottom line is that you have to believe the biopsy. PSMA PET will not show microscopic disease, which is why it cannot "rule out" disease in lymph nodes or elsewhere. It is comforting when it is negative, but it is not absolute truth. A few questions; What was the PSA at the time of the PSMA PET...
Would you treat elderly patients with early-stage gastric cancer with perioperative FOLFOX or FLO (FLOT without T)?
I am actually not sure why the official FLOT regimen used a 24-hour 5FU infusion. In the progression from the Mayo 5-day bolus regimen and the Roswell Park weekly regimen, the use of infusional 5FU reduced the toxicity of combinations with oxaliplatin and irinotecan. See the NCCTG N9741 study (Goldb...