Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred approach for patients with anti-phospholipid syndrome with recurrent thrombosis on coumadin and LMWH?
This is a difficult condition to manage and personalized approach/risk stratification is key. There are several potential considerations:Warfarin therapy could be intensified, anti-platelet agents could be considered (although not in combination with LMWH).For patients with an underlying autoimmune ...
Do you routinely check for copper deficiency as part of workup for bicytopenia with leukopenia/anemia or pancytopenia?
I do not usually check for this but not unreasonable if there is a clinical reason to check.
In patients with thrombocytosis with negative MPN workup from peripheral blood and bone marrow, is there a role for daily 81mg aspirin or other treatment?
In the absence of an MPN, there is no data to support the use of low-dose ASA. Unless there was extreme thrombosis and acquired von Willebrand syndrome, there would also be little reason to bring the platelet count down as well. In the absence of MPN, thrombocytosis itself is not a risk factor for t...
In what situations would you offer salvage radiotherapy for relapsed/refractory DLBCL?
There are a number of different clinical scenarios when I would consider RT in patients with relapsed/refractory DLBCL. NCCN guidelines (page BCEL-7 and BCEL-8) list RT as an option in several of these settings.1. Relapsed disease s/p autologous or allogeneic stem cell transplantation - In patients ...
When would you consider stopping chronic transfusion therapy in a sickle cell patient with history of abnormal TCDs but no stroke?
Fortunately, we have good data to answer this question. The TWiTCH trial aimed to determine the efficacy of hydroxyurea at maintaining TCD velocities after discontinuation of initial transfusion therapy to prevent primary stroke. Patients on this non-inferiority trial with a history of abnormal TCD ...
In patients who develop a VTE, what conditions do you consider as persistent, provoking risk factors, and at what point are they controlled enough to stop anticoagulation?
Not a lot of controlled trials that address each situation so we rely on expert consensus and judgement, and more importantly, balancing the risk of hemorrhage vs thrombosis. ASH guidelines define chronic persistent risk factors as 1) Active cancer (e.g., ongoing chemotherapy; recurrent or progressi...
What radiation dose and fractionation is appropriate for hairy cell leukemia presenting as an isolated skeletal lesion, where systemic treatment is not recommended?
If the patient is not a candidate for any systemic therapy like cladribine or pentostatin, treatment of the bone lesion to 20-30 Gy with conventional fractionation is a reasonable approach. Some of the older case series would treat lesions up to 60 Gy, but HCL is ultimately a radiosensitive B-cell l...
In patients with high-risk polycythemia vera with a history of thrombosis, should aspirin be used in addition to indefinite anticoagulation and cytoreduction for prevention of recurrent thrombosis?
I do not continue aspirin in patients who require anticoagulation out of concern for an increased risk of bleeding. In an analysis of the REVEAL database, patients receiving anticoagulation in combination with aspirin were over 4-fold as likely to have a hemorrhage (HR [95% CI] = 4.22 [2.57, 6.94]; ...
What induction combination(s) would be appropriate for newly diagnosed standard cytogenetic risk multiple myeloma who have a transplanted kidney?
This is a tough question! On one hand, the risk of allograft rejection with IMiDs is a real concern. On the other hand, one must consider that the evidence for this is limited to case reports/series (ex Walavalkar et al., PMID 29661456; Lum et al., PMID 28189378; Nguyen et al., Blood (2019) 134 (Sup...
In young patients with essential thrombocythemia and early significant atherosclerotic disease but no thrombotic history, would you consider the addition of cytoreductive therapy?
This is a good question without an evidence-based answer. It's important to understand why this person has early atherosclerotic disease, have other modifiable risk factors been identified and addressed? For example, familial conditions that lead to hyperlipidemia, or smoking, obesity, etc. If the p...