Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your first line strategy for TP53 mutant AML?
I think most would avoid induction-like chemotherapy opting for new regimens such as azacitidine + venetoclax. However, in many instances, the mutation panel comes back after you start treatment which provides a real challenge to use this infuriation in real-time. I hope that faster TAT on NGS panel...
How long do you continue treatment with imatinib in a patient with chronic eosinophilic leukemia who achieves remission?
This has not been clearly established. If the patient has the FIP1L1/PDGFR rearrangement, these patients need very low doses for excellent response, typically 100 mg daily. If not, response rates are lower and they usually require higher doses. I would continue therapy indefinitely as TFR has not be...
Do you switch from imatinib to another TKI in patients with chronic phase CML who develop renal insufficiency?
Imatinib has been associated with a decline in GFR. It is not certain (and probably doubtful) that this represents kidney damage. If no other causes can be identified, a change could be appropriate. Bosutinib has been associated with a similar decline so nilotinib or dasatinib might be better option...
How do you manage a patient with progressive cerebellar ataxia and positive cardiolipin antibodies?
I would be very cautious attributing ataxia to the presence of ACL (even if they were persistent). While an association between ataxia and apl has been described, the differential is extremely broad and should be carefully worked up in conjunction with a neurology team. Some of the more common cause...
Based on recently published data from COG ANHL12P1, how will you use crizotinib in pediatric and AYA patients with ALK+ anaplastic large cell lymphoma?
I would discuss brentuximab (plus ALCL chemo backbone) with newly diagnosed ALCL with patients and families in the absence of any open trials. The published COG data looks favorable but hasn't been shown in a randomized setting to improve EFS/OS. With the VTE data (and the availability of Brentuxima...
Do you use anticoagulation in cancer patients who develop an unprovoked superficial vein thrombosis?
It depends on the extent of the thrombus and clinical circumstances. Superficial vein thrombosis is triggered by the presence of malignancy. For distal minimal symptomatic thrombosis, I would consider time limited anticoagulation. For more proximal and symptomatic thrombosis, I would consider more e...
Do you check beta 2 microglobulin in patients with MGUS?
I think this question can be answered in two ways - firstly, from the vantage point of clinical utility, and secondly, from the vantage point of cost-effectiveness. I think the short answer to both is no. For patients with suspected smoldering MM awaiting bone marrow biopsy, PET-CT, wbMRI, etc. I ...
When patients develop headaches from luspatercept, do they tend to improve over time?
I've seen two common scenarios with this. One is headaches related to hypertension as a result of luspatercept. By treating the hypertension, the headaches often improve. If the headaches are in the absence of hypertension, I do use a low dose beta blocker to see if it helps, and have had some resul...
What precautions do you take prior to CABG in a patient with sickle cell trait?
Surgery and anesthesia are safe in sickle cell trait (HbAS) when normal precautions are followed. In patients with HbAS and control subjects, the frequency of anesthetic, surgical, and postoperative complications was similar; however, most patients were young, and few thoracic procedures were includ...
For T cell ALL treated in CR (without transplant), how often do you do BM biopsies as part of surveillance, and for how long?
The role of surveillance bone marrow exams in ALL (either B or T-lineage) is a matter of some debate. Thoughtful clinicians can disagree, but in my practice, I do NOT routinely perform these procedures, instead reserving them for signs or symptoms suspicious for relapse. This is analogous to how the...