Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you use pembrolizumab to treat patients with BCG-refractory Ta or T1 NMIBC without CIS?
Pembrolizumab FDA-approved indication includes BCG-unresponsive CIS with or without papillary tumor in patients who refuse or cannot undergo radical cystectomy based on the cohort A of KEYNOTE-057 trial. The question of data extrapolation to BCG-unresponsive Ta or T1 without CIS is a reasonable one....
How do you approach the initial dosing of carfilzomib for patients with relapsed multiple myeloma?
A great question and one without a uniform answer! I place a lot of focus on patient quality of life, and one of the recurring themes from patients is the number of visits to the medical center. A twice-weekly regimen of carfilzomib (or bortezomib for that matter), over the course of a year, results...
How would you manage a patient with acquired von Willebrand disease who requires DAPT for arterial disease?
Acquired vWF has many causes: lymphoproliferative disorders; MPN; autoimmune disorders; high flow disorders (Heyde syndrome) and drugs. Treating the underlying disorders would be the safest strategy because DAPT is going to cause bleeding per se in some patients and removing a second cause for bleed...
In the absence of symptoms would you still treat high risk myelofibrosis if transplant ineligible?
If a patient with high risk PMF is not a transplant candidate, any therapy is, by definition, palliative and in the absence of symptoms, the potential risks of therapy would theoretically outweigh its benefits (e.g., anemia, leukopenia, or thrombocytopenia). The presence of asymptomatic leukocytosis...
Would you treat iron deficiency in post PV myelofibrosis if anemia is the predominant concern?
Absolutely would treat with IV iron. I have discussed this with KOL's and there is unanimity. You may buy a protracted period with anemia control. Not giving it is ill-considered. Where there is disagreement, is in the P Vera patient in excellent control, not anemic but with symptomatic iron deficie...
What is your approach to pRBC transfusion support for myeloma-related anemia?
There is likely not a single right answer to this.The data suggests that a hemoglobin threshold of 7 g/dL is reasonable for critically ill patients rather than a higher threshold. The Clinical Practice Guidelines From the AABB recommend a threshold of 7-8 g/dL. In general, I follow these rules: Tran...
Is there a role for liver transplantation in an initially unresectable HCC with a complete response after bevacizumab-atezolizumab?
I have had one patient who successfully underwent liver transplantation after an excellent response to atezolizumab plus bevacizumab. The patient was young and otherwise healthy. Further, he was taken off treatment and had no recurrence after 2-3 months off immunotherapy before being considered for ...
Do you offer consolidation durvalumab in stage III patients with NSCLC who developed grade 2 radiation pneumonitis during chemoradiation?
The cleanest answer is no, I would not put a patient on durvalumab who experienced pneumonitis during radiation. This is in keeping with the clinical protocol for the PACIFIC trial which excluded patients who experienced any grade pneumonitis during radiation (including grade 1). The reason we now o...
What is your preferred first line regimen for PDL1-negative squamous cell lung cancer?
Firstly, I think clinical trials, where available, should be considered for all patients particularly those with squamous and/or PD-L1 negative tumors as the benefits from chemo-IO in this setting have not been as striking as in PD-L1 positive or non squamous tumors, we have more work to do to impro...
When determining frontline treatment for NSCLC, would you incorporate molecular predictors of resistance to immunotherapy such as STK11, KEAP1, p53?
This is a great question and there are a number of first line trials that I hope will be able to answer this. I do believe that we should be evaluating these patients specifically for trials (i.e., NCT04265534). I also think looking at these data across the current studies including CM227 and 9LA wi...