Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you counsel patients with a curable breast cancer that there is no indication for additional surveillance imaging after treatment other than continuing annual mammograms?
This is certainly a difficult question to address. I acknowledge and validate the patient’s fears first. When breast cancer patients complete their primary therapy (often after they are stable on hormonal therapy or complete a year of Herceptin), and we begin talking about seeing them every 3 month...
How would you manage distal DVT in first trimester of pregnancy?
This is an excellent question. Essentially, this is an individual with an acute, provoked distal DVT in the setting of pregnancy. ASH 2018 guidelines for management of VTE in pregnancy recommends antithrombotic therapy with LMWH for individuals with acute VTE (Bates et al., PMID 30482767). While the...
What antibiotic, antifungal and antiviral prophylaxis you give post CAR-T therapy, and what is the duration?
This is a critical issue as more patients are being treated with CAR-T cell therapy. My approach would be as follows: Antiviral PPx: I usually consider acyclovir PPx for at least 1 year Antifungal PPx: Consider fluconazole PPx for initial neutropenia if it is prolonged beyond a week ---> once the c...
For von Willebrand type 2B, do you expect a decline in platelet count over time as vWF increases with age?
Von Willebrand factor levels increase with age in normal people and in those with type 1 VWD. There is no or a much lesser degree of VWF rise in variants type 2 and 3. I would not expect a significant decrease in the platelet count in a patient with type 2B with increasing age, but if it occurred, ...
At what ferritin threshold would a patient with anemia of inflammation or malignancy no longer benefit from iron supplementation for functional iron deficiency?
There is no level. I have given IV iron to people with low TSATs and ferritins in the thousands. 200 isn't even close to too high.
Do you avoid ESA use in patients with anemia and chronic kidney disease who also have APLS and risk for thrombosis?
I normally don't. I would make sure the patient is getting anticoagulated if indicated. I don't believe making the hemoglobin closer to normal in the setting of being anticoagulated increases thrombosis risk that much. I would shoot for a hemoglobin goal of 10-11.
How do you approach a recurrence of grade 3 anaplastic astrocytoma after initial treatment with gross total resection followed by RT/adjuvant temozolomide?
As the questioner notes, this is an area where guidelines and published evidence are not as satisfying as we would like, so treatment has to be individualized. In addition, most trials until very recently did not test IDH status or 1p/19q status so the diagnoses may not be the same as people diagnos...
What is your approach to treating limited stage DLBCL of the colon?
Often times patients with CSIE DLBCL of the colon will receive the diagnosis after a hemicolectomy intended to treat presumed colon adenocarcinoma. In such cases, I will routinely offer short-course chemotherapy consolidaton (3 cycles of RCHOP chemotherapy, most commonly; R-da-EPOCH can be considere...
What is your approach to treating limited stage DLBCL of the colon?
Often times patients with CSIE DLBCL of the colon will receive the diagnosis after a hemicolectomy intended to treat presumed colon adenocarcinoma. In such cases, I will routinely offer short-course chemotherapy consolidaton (3 cycles of RCHOP chemotherapy, most commonly; R-da-EPOCH can be considere...
Is there safety data regarding the use of hormonal IUDs in patients with atypical ductal hyperplasia and other high risk, non-malignant breast lesions?
In searching the literature, I find nothing specifically about progestin-based IUDs and women at increased risk of breast cancer. Some studies, however, have found that hormonal birth control methods, including intrauterine devices (IUDs) containing progestin, may slightly increase the risk of breas...