Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you optimally manage a patient with a MDS/MPN overlap syndrome who has both transfusion-dependent anemia and marked thrombocytosis?
Patients with MDS/MPN marked by severe anemia and thrombocytosis likely have the MDS with ring sideroblast with thrombocytosis (MDS-RS-T) subtype and have a high frequency of SF3B1 and JAK2 mutations. Clinically, they resemble a fusion of MDS-RS and essential thrombocythemia (ET), both of which tend...
Is there any role for iron chelation in a patient with iatrogenic transfusion-induced iron overload such as in patients with end-stage kidney or liver disease?
There is a point with transfusion that iron overload starts to cause significant organ damage. With the advent of deferasirox (Jadenu), oral iron chelation can maintain equilibrium with ongoing transfusion. I would not start till ferritin is 1500 or higher to avoid risk of chelation of other heavy m...
When do you use clinical decision tools, like HERDOO2 or DASH, to determine duration of anticoagulation in venous thromboembolism?
I do not use the clinical decision tools as I find that they do not properly account for all variables that impact anticoagulation decision-making in a patient-by-patient case.
What are your top takeaways in Breast Cancer from ASCO 2023?
SONIA: A notable trial comparing CDK4/6 inhibitors as 1st line vs. 2nd line treatment. AI+CDKi combination therapy as 1st line does not improve OS, 2nd PFS, or QOL compared to combination therapy as 2nd line. Factors such as the site of metastasis, tumor burden, symptoms, cost, and side effects sho...
What is your bilirubin threshold to treat a metastatic pancreaticobiliary tumor with FOLFOX?
I am not aware of any particular threshold, but as the clearance of 5-FU and oxaliplatin is minimally affected by hepatic dysfunction, both drugs can be used. In my personal experience, I have treated patients with bilirubin more than 10 with FOLFOX (generally without a 5-FU bolus which likely has m...
How do you manage a patient with no history of miscarriage but who is unable to conceive, who has a positive lupus anticoagulant without diagnosis of antiphospholipid syndrome?
I would be very leery of linking infertility to a positive lupus anticoagulant result. Whether or not the patient has antiphospholipid syndrome the evidence linking antiphospholipid antibodies to infertility (as opposed to loss of an established pregnancy) is somewhere between weak and nonexistent. ...
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...
What is the appropriate dose of radiation for a primary osseous non-Hodgkin's lymphoma?
Acceptable doses range from 30 Gy to 45 Gy. Would consider 30 Gy if there is a metabolic complete response after 2 cycles of R-CHOP and the patient got at least 4 cycles total. 45 Gy is the dose used in the prospective TROG trial of bony DLBCL, so it has some data behind it. In the femur, the bigges...
When should paclitaxel (or other chemo) be discontinued in de novo metastatic triple negative breast cancer with high PDL1 in favor of continuing pembrolizumab alone with good treatment response?
The KEYNOTE-355 trial was designed so that investigators continued chemotherapy until "confirmed disease progression or unacceptable toxic effects had occurred or withdrawal of consent or physician’s decision" (Cortes et al., PMID 35857659). I think this is a good strategy. It's not a satisfying ans...
What is the role of EGFR inhibitors in patients with metastatic transverse colon cancer?
This is a very tricky question since all the studies including meta-analysis have not clearly addressed this question. If we believe the overall survival difference we observed is truly due to the primary tumor location (sidedness) that is possibly due to the right sided colon being from the midgut ...