Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you recommend oral or intravenous iron in a chronic kidney disease stage 4 patient who is not on an ESA and has a hemoglobin of 12.7 g/dl and an iron saturation of less than 20%?
I would not necessarily treat this patient with iron at all. I would check serum ferritin. If low would do a colonoscopy or look for causes of iron deficiency. If not low would observe. In general though for patients with CKD (not on dialysis yet) who need iron therapy, I would try oral iron first. ...
For incidentally found stage I indolent non-Hodgkin's lymphoma in young patients, which subtypes would more strongly warrant a consideration for curative-intent radiation?
In general, national guidelines recommend definitive RT for early-stage, low-grade NHLs. These are a diverse collection of diseases with different natural histories and outcomes after treatment. In brief... 1. Follicular lymphoma - typically a disease of older adults with ~20% presenting with early-...
For plasmablastic lymphoma responsive to treatment except for a recurrent lymph node eroding into a vertebral body at the end of chemotherapy, would you cover the entire vertebral body in your CTV, or treat only the involved lymph node with a margin?
Plasmablastic lymphoma is an aggressive NHL that typically occurs in the H&N region, typically in immunosuppressed individuals. Most patients present with advanced disease. The role of RT is not firmly established. That said, in a patient only achieving a PR to systemic therapy with localized residu...
Does variable allele frequency (VAF) of JAK mutation affect your clinical decision-making in MPN in any scenario?
The JAK2 driver mutation quantitative allele burden is an important feature in the clinical management of PV, ET, and PMF patients. First, however, some prefatory comments: All MPN driver mutations are classified as variant because they contain a change in their DNA not normally found in the particu...
Does variable allele frequency (VAF) of JAK mutation affect your clinical decision-making in MPN in any scenario?
The JAK2 driver mutation quantitative allele burden is an important feature in the clinical management of PV, ET, and PMF patients. First, however, some prefatory comments: All MPN driver mutations are classified as variant because they contain a change in their DNA not normally found in the particu...
What systemic therapy and dose adjustments would you implement for patients with pancreas cancer and cirrhosis with pancytopenia?
Of the five drugs available to us, two (abraxane and irirnotecan) are a challenge in liver dysfunction with the added thrombocytopenia. The question becomes, what is the real value of a single drug versus a combination in this setting when it comes down to clinically meaningful efficacy? Capecitabin...
Do you consider starting hydroxyurea in a patient with hemoglobin S-beta thalassemia with chronic kidney disease secondary to FSGS?
I consider initiating hydroxyurea in all individuals with sickle cell disease, even if they have rare or infrequent acute pain episodes. This is because pain is just one manifestation of the disease and ongoing hemolysis leads to a state of chronic inflammation characterized by cytokines, activation...
Would you consider giving neoadjuvant therapy using a KEYNOTE-522 regimen to someone with cT1c cN0 TNBC?
I would treat a larger cT1cN0 TNBC in a young, fit patient with neoadjuvant ddAC-T. As you point out, such a patient would not have been eligible for KEYNOTE-522 (which only enrolled stage II-III patients), and I do not think the added potential toxicity of the pembro and carbo are worth the unknown...
How do you treat stage I head of pancreas adenocarcinoma in an older patient who is not a candidate for chemotherapy or surgery?
The question of how to manage an elderly patient who is not a candidate for chemotherapy or surgery is a really important one. I would argue that this question is not unique to an elderly patient but should be asked for ANY patient who cannot receive systemic therapy. We are fortunately living in a ...
Can the presence of elevated ring sideroblasts (20%) on a bone marrow biopsy without dysplastic changes or suspicious molecular mutations still be indicative of an underlying MDS in a patient with unexplained anemia?
It is easy to forget that this clinical presentation was the rule not the exception in the pre-genomic era. We knew then that idiopathic sideroblastic anemia could be congenital or acquired due to drugs, toxins, or disorders of porphyrin or hemoglobin synthesis, or could rarely be clonal (using G6PD...