Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Given results of the ELEVATE-RR study, would you consider use of acalabrutinib in all patients with previously treated CLL, or restrict it to certain patient populations?
Efficacy and safety are both important for evaluating new therapies. The ELEVATE-RR study demonstrated equivalent efficacy with a hazard ratio of 1.0 which indicates response duration was identical. Notably, several indications of safety were better which then would tilt the benefit to using an alte...
In the rare setting of enoxaparin injection-induced abdominal wall hematoma in patients requiring long-term anticoagulation, what is your timeline for restarting anticoagulation?
Abdominal wall hematomas typically occur when a vessel has inadvertently been injured during injection. Timing of resumption of anticoagulant will vary with the underlying indication for anticoagulants. For a high-risk indication, eg multiple cardiac valves in patients with history of stroke, I woul...
What is your approach to CLL in patients with atrial fibrillation and/or on anticoagulation?
Before the availability of venetoclax, the only approved targeted oral therapy for patients with CLL was ibrutinib. Given the lack of alternative options, patients with atrial fibrillation and/or patients on anticoagulation were treated with ibrutinib. Use of anticoagulation with ibrutinib can incre...
Do you find ELEVATE-RR data and study design compelling to start preferentially using acalabrutinib over ibrutinib?
The inferiority design of the ELEVATE-RR included a 1.429 margin, but the hazard ratio between treatments was 1.0 as related to DFS and 0.82 (favoring acalabrutinib) for OS. This improved OS likely is reflective of lower cardiac events and other adverse events. To me, this is sufficiently beneficial...
What is your preferred maintenance strategy for high risk multiple myeloma?
Ok. First off, what is high risk in the setting of maintenance therapy? I define high risk in this area as R-ISS 3 [incl t(14;20)], ≥ 5% circulating PCs, extramedullary disease [except salivary glands], hypodiploidy, or karyotypic t(8;22). We frequently argue about this definition since there is no ...
For frail patients with cardiac co-morbidities and relapsed CLL with high cytogenetic risk, what are some considerations for using continuous acalabrutinib over fixed duration therapies such as venetoclax/rituximab?
This is a complicated question and I evaluate each patient individually. I worry more about patients with reduced cardiac function on BTK inhibitors than I do those with pre-existing atrial fibrillation, and if they are on anticoagulation as well, that is a further concern. If the patient has reduce...
How would you manage a CLL patient who experienced severe infusion reactions with rituximab and has exhausted all other options?
This is a relatively common question and very relevant to clinical care. Rituximab, Ofatumumab, and Obinutuzumab do target CD20 but all should be viewed as we would view different structural classes of drugs. In general, if one has a very bad reaction to rituximab, depending upon what it is, one can...
What regimen would you offer a young patient with T-cell ALL who recurred a short time after allo-transplant and was initially treated with CALGB10403?
The answer is always clinical trial if feasible. If only commercial options: Assuming morphologic relapse, I tend to favor peg-asp containing regimen if the patient is fit enough to receive – especially if ETP variant. I like SMILE, but important to stress that regimen may come with considerable mye...
How do you counsel patients referred for abnormal light chain ratio when individual light chains are in normal range?
It appears you are referring to a situation where the uninvolved light chain is quite suppressed and the potentially involved light chain is normal, generating an abnormal ratio. There are other situations such as in CKD where both kappa and lambda light chains will be elevated but the ratio will be...
Should we recommend the COVID-19 booster vaccine to patients who had a DVT or any other complications such as hemolytic anemia or thrombocytopenia from prior vaccine doses?
There are a few case reports of VTE following COVID-19 vaccinations (approximately 10 based on my PubMed review today). However, VTE has a high incidence of 0.1% in the general population and much higher after age 45 (Mary Cushman, PMID 17433897), so determining a causal relationship between the vac...