Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For a Jehovah's Witness patient with multiple myeloma, could you safely offer a BCMA-directed bispecific antibody or CAR-T therapy?
Short answer is - yes! Long answer is - it depends. Patients can be optimized leading into CAR T-cell therapy by using ESAs and possible TPO agonists, iron, B12, folate supplementation. The main issue is around propensity for anemia and thrombocytopenia, especially if profound and prolonged. Patient...
Would you extrapolate from EMBARK to use an ARPI other than enzalutamide in high risk biochemically recurrent prostate cancer for a patient with contraindications to enzalutamide?
This is a good question and my general answer is no, as no other ARSI has a phase 3 trial in this nmHSPC setting showing similar benefits. PRESTO was a smaller phase 2 trial of ADT/apalutamide but did not measure or report MFS or OS and was underpowered to look at these endpoints. However if a patie...
Would you offer adjuvant osimertinib in a patient with complete pathologic response to neoadjuvant platinum doublet for a stage IIIA resected EGFR mutant lung adenocarcinoma?
With the caveat that we do not have level I evidence specifically for this clinical scenario yet (ongoing NeoADAURA study may potentially provide some answers in the future), based on very favorable outcomes of patients with NSCLC in general who derived pathologic complete response after neoadjuvant...
Is a bone marrow necessary in patient with splenomegaly and polycythemia vera?
Yes. Bone marrow is necessary in a patient with polycythemia vera and splenomegaly. There is a possibility of missing ET or associated primary or secondary myelofibrosis. The only way to distinguish between the three bcr-abl negative MPN namely MF, ET, and PV is by performing a bone marrow biopsy an...
How would you approach a bulky 9 cm DLBCL of the axilla following an excisional biopsy to negative margins?
This is a valid question that is encountered with some regularity in clinical practice. It has also been reported in clinical trials. For example, in the landmark SWOG study, 29% of patients had all gross disease resected at the time of diagnostic biopsy. This was in the pre PET-CT era. In the more ...
Do you hold IV iron in the setting of active infection?
While there is no evidence of harm, there is enough conjecture about the danger to make it prudent to wait until infection is controlled. So yes, I do. Further because of the iron restricted erythropoiesis during infection, the efficacy is likely to be blunted.
What recommendations do you have for a transgender female patient with history of prothrombin gene mutation who is interested in starting gender affirming hormone therapy?
A review of the literature suggests that the risk of VTE associated with hormone therapy in this setting is quite low, even in the presence of other risk factors for clotting (see, for example, Mullins et al., PMID 33753543). Furthermore, the presence of an asymptomatic prothrombotic genotype is rar...
Do you consider discontinuing maintenance therapy in transplant-ineligible patients with Multiple Myeloma?
In absence of side-effects or relapse/progression, I continue maintenance in a dose-attenuated fashion for TI-NDMM based on available evidence in literature. I do encourage patients with standard risk disease to participate in trials asking the MRD-driven duration of maintenance question.
Do you routinely send NGS testing from bone marrow samples in patients with unexplained cytopenia or cytoses?
For patients with unexplained cytopenias in whom I suspect MDS or MDS/MPN, I will often obtain a broad NGS panel for myeloid malignancy gene mutations. The goal is to aid in diagnosis (and prognosis once the diagnosis is made), but I do not rely on the NGS panel alone to make the diagnosis. A bone m...
Do you recommend IVIg and/or cytoreduction for patients with IgM MGUS with reciprocal depression in IgG and recurrent infections?
Treating MGUS due to immune suppression is not a common practice. If IgG level is severely depressed below 200 mg/dl with recurrent bacterial infection, I would administer IVIG.