Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you determine when to use a maintenance regimen vs continuous 3-drug regimen in a transplant-ineligible MM patient after response to first line therapy?
After completing initial therapy (which may or may not include high dose melphalan and auto SCT), I typically use maintenance lenalidomide. I consider “dual maintenance,” which is combining lenalidomide and a proteasome inhibitor, for patients with high risk FISH: t(4;14), t(14;16), and del17p. 1q g...
For patients with multiple myeloma, when using Lenalidomide or Pomalidomide, how do you approach dose adjustment based on patient tolerance?
In general, my approach is to try to keep patients on the intended dose of an IMiD for as long as they can tolerate it (within reason). I think early dose reductions can be avoided by dedicated supportive care. For rashes, using antihistamines and topical corticosteroids can help. For diarrhea, imod...
How do you manage insomnia in cancer patients that is refractory to traditional sleep aides?
Insomnia and other sleep disturbances are very common in individuals diagnosed with cancer, and it is often helpful for patients to hear this. A good history of other contributors to sleep disturbance can be helpful as well. Often, depression, anxiety, and pain, as well as other stimulant medication...
What initial workup do you perform when there is a concern for porphyria?
This is a terrific question. But a broad question. Porphyria refers to a defect in heme biosynthesis leading to the accumulation of porphyrins and porphyrin precursors. We should remember that there are three general categories of porphyria based on clinical manifestations: acute hepatic porphyria (...
What is the anticoagulation recommendation for a chronic DVT?
Simply having a chronic DVT is not an indication for anticoagulation. In general, acute provoked VTE requires a minimum of 3 months of anticoagulation. For an unprovoked VTE, there are scoring systems that guide towards limited duration vs long-term of anticoagulation. So it depends on where the fin...
How do you incorporate blinatumomab into therapy for a pediatric or AYA patient with isolated CNS relapse of B-ALL, if at all?
I try to prioritize CAR-T in this setting. Getting there depends on logistics such as financial clearance/collection though. If late relapse or if there is a delay in getting CAR-T, would treat with AALL1331 Arm D (with XRT in mtn), substituting block 3 of blina for block 3 on Arm C (to get more CNS...
How would you approach first-line treatment in metastatic NSCLC for a patient with ALK-EML4 V3a/b variant and MSI-high status?
It's a good question. I would first confirm the MSI-high status using tissue-based testing. I would recommend a pathology re-review in light of these molecular findings, and consider the possibility that this could be metastatic colorectal cancer. While EML4-ALK fusions are most common in NSCLC, the...
If a patient with non-metastatic prostate cancer is found to have a BRCA mutation, should this influence treatment recommendations for local therapy?
While there are no randomized trials to address this question, one prospective, non-randomized study of BRCA2 carriers with localized prostate cancer suggested improved outcomes with lower relapse rates in men treated with radical prostatectomy as opposed to radiation therapy. See: Castro et al., Jo...
For unfavorable intermediate prostate cancer in elderly patients, would you consider radiation without ADT?
This is a great and highly clinically relevant question that I view has 4 important inter-related points.First, I will take the liberty of rephrasing the question as I believe the real question is... for a man with a good enough life expectancy to warrant curative intent RT, does age and comorbid co...
When do you initiate androgen deprivation therapy for biochemical relapse of prostate cancer following primary therapy?
There is no right or wrong answer here. The Johns Hopkins approach is to always recommend a clinical trial for the nonmetastatic BCR population. In the absence of a trial, our group does not believe that early ADT is justified in men with PSADT >9 months, where metastasis-free survival approaches 10...