Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What clinical factors impact your upfront treatment decisions in transplant-ineligible MM?
My approach is to start with up-front adjustments in choice of drugs, dose, and schedule based upon many factors: age, organ function/other comorbidities, concurrent medications, insurance/other economic factors, personal physical mobility, and access to transportation, patient goals, etc.Myeloma tr...
Are there any circumstances in which you would recommend adjuvant chemoradiation for resected olfactory neuroblastoma?
Agree with Dr. @Dr. First Last. Our experience treating 29 patients with Kadish B and C neuro esthesioneuroblastoma with local RT if positive margins, and no neck RT when the neck was N0, resulted in 27% neck failure including in the contralateral neck. 5-year LRF rate was 29% in patients who did no...
What is your approach to platelet transfusion in heparin induced thrombocytopenia?
In general, I avoid giving platelets in intensely prothrombotic disorders, except in the circumstance of severe bleeding. Severe thrombocytopenia is uncommon in HIT, though DIC may occur in some patients. However, bleeding is relatively uncommon and platelets not generally necessary.
How would you treat a patient with metastatic clear cell renal cancer who has progressed on immunotherapy and developed bleeding on cabozantinib?
This is not an uncommon situation. Any VEGFR inhibitor can indeed raise the risk of bleeding. An answer depends on the details of the bleeding-like one episode vs ongoing chronic bleeding, severity, arterial vs venous, location, GI vs CNS vs elsewhere, other contributing factors like anti-coagulants...
What dose of PEG-asparaginase do you recommend for teens with high BMI treated on a pediatric ALL regimen?
For older adolescents and young adult patients, the optimal dosing of peg-asparaginase is unclear. It is recognized that asparaginase toxicity increases with age, but also with certain comorbid conditions such as diabetes, liver disease, and obesity (BMI >30). The adolescent and young adult (AYA) AL...
Would you offer adjuvant chemotherapy to a young adult with undifferentiated embryonal sarcoma of the liver?
This is an "ultra" rare and interesting entity, predominantly seen in the pediatric population, but I have seen a few in adults. This should not be confused with embryonal RMS - totally different entity. Clearly there is no data, and there will never be any data to support an evidence-based recommen...
Is there an absolute IgM level, in an asymptomatic patient on surveillance that initiation of therapy would be considered for Waldenstrom's macroglobulinemia?
The rate of progression of a paraprotein in a plasma cell disorder or LPL is always concerning, but it's not enough to bring about action. That said, we clinicians are always looking for bad behavior by cancer cells -- these are the indications for treatment more than the rate of rise or attainment ...
For a patient with MM progressing on a daratumumab-based regimen, is it preferable to entirely switch drug class or is another monoclonal antibody such as isatuximab an acceptable next step?
Class switch approach appears to give better disease control, isatuximab does not have activity in daratumumab refractory patients (Mikhael et al., PMID 33980831).
Would you recommend adjuvant tamoxifen in premenopausal woman with high grade DCIS and familial CHEK2 mutation who had bilateral mastectomies?
While risk of CBC is higher in women with known PV in CHEK 2 1100delC (Kriege et al., PMID 24918820), bilateral mastectomies offers the greatest risk reduction for this premenopausal woman with high grade DCIS and pathogenic germline CHEK2 mutation. Results from CPM in high risk individuals consiste...
What is the role, if any, for next generation sequencing testing in patients with suspected MPN who test negative for commonly identified mutations such as JAK2, CALR, MPL, and BCR-ABL?
This is a very relevant question and one that comes up often as NGS testing has become widely available. First, it's important to remember that not all abnormal blood counts, high in particular = MPN or malignancy. This is especially true in patients with erythrocytosis as the vast majority of PV pa...