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...
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.
Do you recommend the use of dexamethasone and anakinra as upfront treatment in a pediatric patient with secondary HLH (nonrheumatic) who is too ill to tolerate etoposide?
If there is no concern for new malignancy or systemic infection, then glucocorticoids are reasonable. I use methylprednisolone up to 30 mg/kg/day (max. one gram). Anakinra is a safe and often effective therapy for secondary HLH. It is quick acting and has a short half-life so I use it early. I gener...
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?
I recommend switching drug classes after progression on daratumumab.Isatuximab, like daratumumab, is a monoclonal antibody against CD38. It has been shown to be ineffective after progression on daratumumab. Mikhael et al, PMID 33980831. While elotuzumab is a monoclonal antibody with a different targ...
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...
How often do you monitor thiamine levels in a myelofibrosis patient taking fedratinib?
I give all my patients Thiamine and therefore, I do not routinely monitor thiamine levels in patients on fedratinib. I will occasionally check levels prior to starting.
Do you consider splenic response as adequate to judge efficacy of JAK2 inhibitors in myeloproliferative disorders?
It is the basis for regulatory approval for JAKi, and it is a clear measure of efficacy as it is associated with better clinical outcomes and improved QoL. However, it is not the end-all, be-all for endpoints. As we design studies to test new therapies, we need to move beyond SVR and TSS50 to endpoi...
How would you approach chronic isolated severe non-cyclic neutropenia with negative bone marrow and rheumatologic work-up?
My preference would be to use G-CSF at the lowest effective dose, i.e., the dose that maintains the ANC >1000. The risk of inducing leukemia is low in individuals with idiopathic, chronic neutropenia, but it is positively correlated with the G-CSF dose. There are also other side effects like bone pa...
What further genetic testing would you perform on a pediatric patient with cyclic neutropenia who is negative for the most common associated mutations?
Virtually all autosomal dominant cyclic neutropenia is due to mutation in the ELANE gene. However, all neutropenia that varies over time is not necessarily hereditary cyclic neutropenia, even though the family history suggests so. It would be helpful to know if the family history follows an AD inher...