Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What would be your preferred second line treatment for a frail elderly patient progressing on Rd?
It will largely depend on the degree of frailty. Many of the myeloma therapeutics are well tolerated, even among older adults or those with comorbidities. Factors such as the time spent coming to clinic or to the infusion center matter as well. It is useful to understand the baseline cytogenetic abn...
Would you offer a complement inhibitor to a minimally symptomatic PNH patient with mild non-transfusion dependent hemolytic anemia?
The context would determine whether this patient should receive complement inhibitor. The first consideration is whether the patient has concurrent aplastic anemia or bone marrow failure. Often, patients with aplastic anemia have a small PNH clone that is not clinically significant and does not caus...
In which platelet function disorders would you consider use of Novoseven as opposed to platelet transfusion?
There are now two recombinant activated factor VII (rFVIIa) available in the US. Trade names are NovoSeven RT and SEVENFACT. NovoSeven RT is US FDA approved for use in Glanzmann thrombasthenia. There are case reports of its efficacy in off label use for other inherited platelet function defects. SEV...
Under what circumstances would you consider anticoagulation in a young female patient with persistently elevated factor XI activity?
First, get a baseline D-dimer to see how procoagulant she is at that point. If elevated, long travel on plane, pre-op and post-op for 2 months - consider short-term anticoagulation. If past thrombosis - give lifelong anticoagulation. If pregnant - follow D-dimer; if it goes up, anticoagulate.
Should patients with active multiple myeloma and other gammopathies be routinely vaccinated against herpes zoster?
All patients starting anti myeloma therapy should be on acyclovir prophylaxis, typically starting at 400 mg BID but renally adjusted to 400 mg daily if needed. This provides substantial protection against zoster. Patients may get shingrix but given that their immune response to the vaccine may be su...
How often should you repeat iron testing in patients with hemochromatosis, not on phlebotomy?
I can't think of a reason in the world to not do phlebotomy either therapeutically or through donation until TSAT is around 30 and ferritin is <100. I try to keep my hemochromatosis patients low, not high normal because the propensity for high TSATs makes subclinical deposition easy. I don't think t...
How do you approach treatment of vasculitis in a sickle cell disease patient?
Will highly depend on the vasculitis type and the acuity of the situation. For ANCA vasculitis, approaches based on rituximab and low glucocorticoid doses might be attractive (granted not severe disease, e.g. RPGN, DAH which should require pulse glucocorticoids). For large vessel vasculitis, a si...
Would you routinely use G-CSF prophylaxis in a CMML patient for decitabine-related neutropenia?
I would use G-CSF if the patient is in remission/responding to decitabine and neutropenia, is decitabine induced and not due to CMML. I will not use at diagnosis or when not in remission as neutropenia may be disease-related.
What is the maximum pRBC volume you can transfuse when performing a manual exchange transfusion in an adult-sized patient with sickle cell disease?
It depends on how much hemodynamic stress the patient can tolerate and the rate of the phlebotomy. The rate is usually 30 minutes for every 500 cc whole blood, but may need to slow down in smaller-sized patients (e.g. 50 kg or less), patients with history of pre-syncope or syncope with phlebotomy, a...
How do you approach management of sickle cell patients who mistrust Western medicine and prefer naturopathic therapies?
With compassion and understanding, I would explain that the lifespan of patients with SCD in regions with access to Western medicine far exceeds that where the disease is most prevalent. Controlled clinical trials have proven the utility of hydroxyurea to alter beneficially the course of disease and...