Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach patients with underlying psychiatric disorders who refuse CML treatment due to not believing their diagnosis?
Importantly, having an underlying psychiatric disorder doesn't unto itself mean that the patient lacks the capacity to make their own medical decisions. Further information is necessary about the patient's understanding, their current status, etc., to make that determination. At many institutions, p...
Do you send an antiphospholipid antibody panel routinely for all patients with an unprovoked thrombus?
Yes. My own practice is to perform testing for antiphospholipid antibodies in all patients with unprovoked VTE and also in patients with arterial thrombosis. Testing should include assays for lupus anticoagulant, anti-cardiolipin antibodies (IgG and IgM), and anti-beta 2 glycoprotein I antibodies (I...
How would you manage VTE in a patient with bleeding disorder such as hemophilia?
Management of VTE in a patient with an inherited bleeding disorder depends on the specific disease, the severity of the bleeding disorder, and the past history of bleeding in that patient. In patients with serious past bleeding and low levels of factor, anticoagulants may be contraindicated and loca...
In your practice, do you usually check MMA and B12 simultaneously or start with B12 levels and check MMA only if indeterminate?
I usually check the B-12 level first. If it is very low, I treat and look for a response. If normal in the ambiguous zone, I get an MMA.
When is a lumbar puncture indicated in a lymphoma staging work up for a pediatric or AYA patient?
LP is not necessary in any Hodgkin patient irrespective of stage. LP plus IT chemo is indicated in all advanced stage NHL. The one exception to that is primary mediastinal B-cell with sclerosis which is an intermediate grade lymphoma (similar to Hodgkin) and rarely spreads to CNS. It is true that ...
In what circumstances would you give G-CSF to a patient with severe neutropenia and HLH?
I am not aware of any direct clinical evidence that addresses this question. That said, I would be very reluctant to treat with G-CSF in the setting of HLH. G-CSF is an inflammatory cytokine that might aggravate HLH. Moreover, since the mechanism of neutropenia in HLH is thought to be increased neut...
What factors do you look at while deciding between a daratumumab-based quadruplet induction versus standard triplet induction such as VRd for newly diagnosed MM?
This is becoming an increasingly thorny issue. A few guidelines to keep in mind:1) Dara-VRd has only been studied (thus far) in transplant-eligible patients. So this discussion of Dara-VRd vs. VRd is hard to apply to patients without intent for transplant. 2) When you look at the CASSIOPEIA and GRIF...
How would you approach early stage unfavorable classical Hodgkin lymphoma with metabolic CR apart from a single residual positive node after 6 cycles of ABVD?
If a patient with early-stage, unfavorable HL had an excellent response to 6 cycles of ABVD, but had a single lymph node that only achieved a PR (Deauville 4), then there are two primary options.1. If you judge that the patient has achieved a reasonable response to chemotherapy, suggesting that syst...
At what platelet count would you feel comfortable dosing aspirin 81 mg for coronary artery disease in a patient with ITP?
In a patient with ITP, I would certainly feel comfortable dosing aspirin 81mg daily at a platelet of 50,000 or greater. As you know, the risk of bleeding in a patient with ITP is less than would be expected at a particular platelet count because the circulating platelets in ITP are young and large. ...
What is your preferred anticoagulant for acute portal vein thrombosis?
The most common reason for portal vein thrombosis is underlying portal hypertension from cirrhosis. Thus, treatment choice is limited by the underlying liver disease. If they have liver disease with prolonged baseline PT, coumadin should not be used. Likewise, if they have liver disease, I don't fee...