Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For hypogammaglobulinemia as a complication of successful treatment, do you empirically start prophylaxis with either 400 mg/kg monthly for IVIG or 100 mg/kg weekly for subcutaneous immune globulin?
Most of the data to support IVIG for hypogam comes from CLL literature. Data in those post-transplant and post-CAR T are limited. IVIG has a reputation of being a bit of a panacea, but I challenge that notion. We investigated the implementation of an IVIG stewardship plan to limit IVIG usage just fo...
For hypogammaglobulinemia as a complication of successful treatment, do you empirically start prophylaxis with either 400 mg/kg monthly for IVIG or 100 mg/kg weekly for subcutaneous immune globulin?
Most of the data to support IVIG for hypogam comes from CLL literature. Data in those post-transplant and post-CAR T are limited. IVIG has a reputation of being a bit of a panacea, but I challenge that notion. We investigated the implementation of an IVIG stewardship plan to limit IVIG usage just fo...
Would you consider offering adjuvant Olaparib to a patient with early stage triple negative breast cancer, cT3N0, ypT1aN0, with BRCA VUS who has residual disease after neoadjuvant KEYNOTE-522 regimen?
Patients with TNBC and residual disease have several options. As trials of different approaches ran roughly concurrently, we lack data on how/when to combine, sequence, or choose. The capecitabine and olaparib trials did not include patients on IO therapy that would continue to the adjuvant setting....
What is your preferred chemotherapy when dealing with hepatic visceral crisis in metastatic breast cancer?
This, of course, depends on the cancer's subtype. For patients with ER+/HER2- cancers, I would consider an initial trial of endocrine therapy and a CDK 4/6 inhibitor (and ovarian function suppression if the patient is premenopausal), based on results from the RIGHT CHOICE study presented at SABCS 20...
What changes do you make in the management of non-endemic nasopharynx cancer compared to endemic?
a) There are 3 varieties of NPC; EBER +ve, HPV +, and non-viral There is only decent data for Induction (IC) for EBER +ve for a small survival benefit with cis-gem, and the group's follow-up suggested that pre-treatment DNA titers only showed benefit for those with high titers. I am not a HN med onc...
What is the goal of estradiol levels on ovarian suppression and AI for breast cancer?
This is a sneaky difficult question. We've known since George Beatson that estrogen was important for breast cancer, and the Early Breast Cancer Trialists Collaborative Group helped get Tamoxifen approved in 1978. I've heard it said that we've had more trials looking at estrogen therapy for breast c...
How do you decide between using ropeginterferon alfa-2b and peginterferon alfa-2a in MPN?
In general, I favor ropeginterferon as it is FDA-approved and allows for less frequent, every 2-week dosing as compared to peginterferon which is used off-label and requires weekly dosing. However, ropeginterferon is not currently approved for ET and in patients where I decide to use interferon in t...
What special considerations do you take when treating cancer patients with severe intellectual disabilities?
Caring for patients with any type of disability is both a privilege and a challenge. Severe intellectual disability poses additional challenges due to logistical, ethical, and moral dilemmas. Additional factors including patients' socioeconomic status, support system, language spoken to individuals ...
Would ITCs in a single axillary node push you towards recommending adjuvant chemotherapy for a young woman with a T1a (<2mm) triple negative breast cancer?
The impact of ITCs in axillary nodes has been a subject of debate. de Boer et al., PMID 19675329 reported that adjuvant therapy reduced the risk of subsequent events in those with isolated tumor cells compared to those who did not get adjuvant therapy (hazard ratio 0.66, CI 0.46-0.95). However, a tu...
Do you do prophylactic LP/IT chemotherapy in high risk APML prior to starting consolidation?
Extramedullary disease such as CNS involvement is quite uncommon at diagnosis in acute promyelocytic leukemia (APL). However, it can be seen in patients with relapsed disease. Both isolated CNS relapse and CNS relapse associated with morphologic or molecular relapse can occur. Yet one has the impres...