Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Why are hypomethylating agents as single agents not approved yet by FDA for treatment of AML (technically off-label)?
DNA hypo methylation gets agents are not approved as single agents for treatment of AML as Phase 3 studies with both azacitidine and decitabine vs treating physician choice of best alternative regimens failed to meet their primary end-point of statistically significant improvement over-all survival ...
What dosing schedule of cladribine do you use for newly diagnosed hairy cell leukemia in need of treatment?
Great question. For patients who meet criteria for treatment and have classic hairy cell leukemia, both the 7-day continuous infusion of cladribine and the 5-day daily dosing seem to have equal efficacy and toxicity. I think either is fine and patient preference can be considered. The 5-day scheme s...
How would you manage a patient with minimal residual disease (<1% of CD25 positive cells) six months after completing therapy with 2-CDA for Hairy Cell Leukemia?
This is a challenging question. Patients with HCL who have MRD after treatment with cladribine or pentostatin have shorter remissions than those who have pathologic remissions. Several studies have shown eradication of MRD with subsequent treatment with rituximab. Thus, utilization of rituximab afte...
How would you treat low grade follicular lymphoma with diffuse epidural involvement? Would you give intratheracal or high dose systemic methotrexate in addition to systemic chemoimmunotherapy?
This is a rare presentation of follicular lymphoma especially if its primary epidural lymphoma without presentation outside the epidural space. This entity was traditionally treated with combined chemotherapy and radiotherapy and associated with a poor prognosis of less than a year. I would conside...
Do you make diagnostic lumbar puncture part of routine work up for newly diagnosed AML if patient is asymptomatic?
Unlike acute lymphoblastic leukemia (ALL), central nervous system (CNS) involvement by acute myeloid leukemia (AML) occurs in less than 5% of patients at the time of diagnosis. Therefore, routine lumbar puncture is not recommended for asymptomatic patients. Certain clinical and biological features h...
How much later after starting a hypomethylating agent in an elderly patient with AML being treated in the upfront setting can venetoclax be started?
It can safely be started at that time, but the outcomes may not be quite as optimal as when used from cycle 1. There is not much data about this, but when used after patients have had progression with prior exposure to hypomethylating agents, responses are sometimes not as robust (see ASH abstracts ...
How would you approach therapy for a patient with newly diagnosed non-GC DLBCL with previous anthracycline exposure?
For fit patients with prior anthracycline exposure for non-lymphoma healthcare who are fit for chemotherapy and with preserved LV function, I would recommend considering daR-EPOCH. The history of the regimen was its original development as treatment of relapsed lymphoma after 1L bolus doxorubicin, a...
What is the role (if any) for Rituximab in a patient with CD20+, Philadelphia chromosome positive ALL?
There are no good randomized data in PH+ disease, but the incorporation of rituximab for CD20+ and PH+ ALL has been standard practice on MD Anderson trials of HyperCVAD+TKI. The challenge has been more on the insurance side - but our approach is to include it if approved.
What factors do you consider when interpreting post treatment PET Deauville scores for patients treated with chemotherapy for classical Hodgkin Lymphoma?
PET-CT interpretation using Deauville Criteria (5 point scale) provides a more objective and descriptive methodology than previous scoring systems. However, there are still numerous limitations and challenges and I suspect refined methods to report PET-CT responses will evolve in the future. I utili...
How do you dose midostaurin in patients with AML who need azole antifungal prophylaxis?
Patients with acute myeloid leukemia are often neutropenic due to the disease or treatment. Anti fungal prophylaxis is often required. The azoles are attractive oral agents. However, they are Cyp3A4 inhibitors. Therefore, for patients taking Midostaurin we use micafungin for anti fungal prophylaxis....