Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients with mild CKD, how do you decide between zoledronic acid and denosumab for bone protection in patients with multiple myeloma?
In this scenario, I prefer zoledronic acid every 3 months with renally adjusted dose. In my experience, the risk of hypocalcemia seems higher with denosumab. Calcium/vitamin D supplementation would be important as well. The every 3 month dosing is an advantage over denosumab, which would have to be ...
How do you manage drug-induced thrombocytopenia when the implicated drug is essential?
I feel obliged to answer this one as a question of medical sociology as much as a direct medical question, because "essentialness" is nearly always in the eye of the beholder, and I have not personally been in the position of the hematologist who has to confront this question with an interventional ...
In a patient with a heterozygous prothrombin gene mutation who has COVID with minimal symptoms, do you recommend prophylactic and/or therapeutic anticoagulation?
If the patient has no history of VTE, I would not recommend any anticoagulant treatment. Heterozygous prothrombin G20210A polymorphism is a relatively weak risk factor for VTE in comparison to antithrombin, protein C, or protein S deficiency, and in general, is not a finding that should guide decisi...
Do you find IgA isotypes of anti-beta2-glycoprotein antibodies and anticardiolipin antibodies to be clinically useful in the evaluation for APS?
I would answer yes to this question. We believe an isolated IgA elevation of AcL or anti-B2GPI carries diagnostic relevance in the right clinical context. We routinely look for all Ig isotypes in our diagnostic evaluation of APS. In fact, our group published the first such article.Murthy et al., PMI...
Would you consider using HMA in management of polycythemia vera?
The short answer is no. However, it depends on what is going on with the patient and what is meant by refractory? If one is managing symptomatic PV or trying to control counts then hydroxyurea, pegylated interferons, and ruxolitinib are the available options and it is worth mentioning that ropeginte...
How long do you give systemic therapies or skin directed therapies to work before changing treatments in patients with diffuse skin limited mycoses fungoides?
It really depends on the patient, the side effects profile. Some systemic therapies are “skin directed” like bexarotene. Also, access to a dermatologist's office for nbUVB is an important factor in making such a decision. I generally don’t recommend topical agents when there is more than 10% eBSA sk...
What is the role of splenectomy versus systemic therapy in splenic marginal zone lymphoma?
With the introduction of rituximab and other CD20 monoclonals, the role of splenectomy in splenic marginal zone lymphoma is shrinking. There are rare clinical scenarios where I would still recommend splenectomy in splenic marginal zone lymphoma; huge splenomegaly with disabling symptoms, splenic tra...
When would you consider an umbilical cord blood transplant over a haploidentical transplant with post-transplant cyclophosphamide, or using a desensitization protocol for high donor-specific antibodies?
High DSA are a real problem. We generally use an MFI of 1000 as a threshold - below that there is less concern. Confusingly, even with high DSA, the rejection rate is not 100% so it is often tough to make a decision. UCB transplantation is somewhat inferior to haplotransplant in terms of overall out...
Should a pregnant woman who is heterozygous for factor V Leiden who has never had a thrombotic event receive prophylactic anticoagulation?
This is a common situation and lacks evidence based recommendations. Recent ASH guidelines (Bates et al., PMID 30482767) suggest against routine antepartum prophylaxis in this situation. However, it is important to have a balanced discussion with the patient. In my experience, most would choose prop...
How do you approach heparin management in patients who have suprathetherapeutic Xa levels on minimal heparin?
Assuming heparin is administered using standard weight-based dosing, that the infusion rate is being accurately monitored, and that the assay was done properly, very high anti-Xa levels that persist despite lowering the heparin dose would be most unusual. In that setting, I would suspect that either...