Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Should consolidation autologous stem cell transplant be considered for de novo follicular lymphoma transformation to DLBCL after achieving a PR with R-CHOP x 6 cycles, if residual disease showed original indolent follicular lymphoma?
First, it is important to make sure that residual disease is FL rather than tFL, which it sounds like you have already done. However, the PET scan should be reviewed; if there is a different node that has very high FDG uptake, then that node should be sampled to rule out residual DLBCL. Historicall...
For an otherwise healthy individual, what would be your front line choice for de novo Richter’s transformation?
The management of de novo transformation of CLL to DLBCL is challenging. For young fit patients, the standard of care remains RCHOP chemoimmunotherapy. Limited data exist exploring other options, including retrospective data sets and small prospective studies, but nothing published convincingly esta...
How would you treat a patient with TNBC who developed progressive disease during neoadjuvant chemotherapy with dose dense AC and weekly paclitaxel?
if the neoadjuvant therapy was sequential, e.g. Ac-Paclitaxel, and progression was not rapid/extensive, could change to the next chemotherapy regimen. In the above example I'd add carboplatin to the Paclitaxel and watch carefully. If still progressing after a few weeks would go immediately to surger...
In light of recent data suggesting limited activity of Atezolizumab monotherapy in the 2nd line treatment of ES-SCLC, would you still offer Atezolizumab maintenance following combination chemo-IO in the first line setting?
The data as single agent therapy in the second line setting should not impact decisions regarding front line therapy. In IMpower133 patients randomized to chemotherapy and atezolizumab continued on atezolizumab if they had stable disease following completion of the chemotherapy plus atezolizumab. Th...
Based on the SELECT-D trial, would you favor rivaroxaban over LMWH for treating cancer-associated VTE in patients with low risk of bleeding?
Both the SELECT-D trial and the HOKUSAI trial provide evidence that rivaroxaban and edoxaban respectively, have a role in the management of cancer-associated thrombosis (CAT). In addition, an oral presentation from ASH 2018, ADAM VTE trial, also supports a role for consideration of apixaban in the m...
Would using Obinutuzumab and Venetoclax second line after Bendamutine and Rituximab be a reasonable option for a patient with IGHV-unmutated CLL?
BR is still an option for frontline CLL, but since Venetoclax +obinutuzumab was approved for frontline therapy, the question you have posed is very relevant. Now it is more important than ever, for the treating physicians to ask what is the therapeutic objective in each case? If we are dealing with ...
For patients with metastatic NSCLC with MET amplification who respond well to first line crizotinib but develop hepatotoxicity, how do you decided whether to consider re-challenge or change therapy altogether?
I think it depends on degree of hepatotoxicity, if lower grade isolated ALT/AST that recovers, would dose reduce and resume and monitor labs weekly initially. For high grade or elevated Tbili with slow recovery, may have to start at very low dose (200-250mg daily and uptitrate as LFT allow). This is...
What is your approach to imaging for localization of biochemical relapse of prostate cancer after radical prostatectomy?
This is a complex question without a short answer. Men with a very low PSA of less than 0.5 have clear benefits from salvage RT after prostatectomy, particularly if they have T3 disease or positive margins; and these patients rarely have PET positive disease, even with PSMA or Axumin imaging. Thus t...
What is your first line treatment of choice for advanced (stage IIIA) follicular lymphoma, histologic grade 1-2 in an otherwise young healthy patient in 2019?
When do you offer consolidative tandem autologous stem cell transplantation for high-risk multiple myeloma?
This is a great deal of debate regarding the question of tandem transplant. In the original IFM 94 study, only patients not achieving a VGPR benefited from a tandem transplant. However, that was in the era of pre-novel therapies. More currently, the BMT CTN 0702 (STAMINA) trial did NOT show a benefi...