Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your institution's practice/guidelines for considering a reduced-intensity (RIC) over a myeloablative (MAC) conditioning regimen?
We don't have an institutional guideline per se. Typically, RIC is used in older patients (e.g. above 60ish), second transplants, people with co-morbidities that preclude high dose therapy, and diseases that are particularly sensitive to immunologic control, or some nonmalignant diseases such as apl...
For a patient with concurrent diagnoses of Hodgkin Lymphoma and Light Chain Myeloma complicated by Myeloma Kidney, how would you approach treatment?
I have seen this once, just once. Two separate but newly diagnosed hematologic malignancies that require treatment simultaneously are rare. More common is a passenger MBL in a myeloma older than 70 y.o., MGUS in the setting of another lymphoid malignancy is not unheard of, and a T-cell gene rearrang...
Do you routinely offer antiviral prophylaxis for patients receiving chemoimmunotherapy?
Yes, with R-CHOP and similar therapies for anyone who may have had chickenpox. I have seen shingles during treatment. I have not been doing routinely for younger patients who had VZV vaccines. Yes also for anyone with a history of HSV. Usually acyclovir BID.
Would you anticoagulate recurrent venous thromboembolism in a patient with Ehlers Danlos syndrome?
Yes, but know the hx of bleeding. Would use low dose Coumadin one 1.5 to 2, have good antidotes for Coumadin.
What are your recommendations for management of patients with familial polycythemia due to EPOR mutation during pregnancy?
This is not a question that has a definitive answer since I know of no reports dealing directly with this uncommon situation and I have never treated such a patient. I have, however, successfully treated many pregnant vera patients, who have a constitutively-active erythropoietin receptor (EPOR) due...
Based on recent data would you consider adding ATRA to low dose rituximab for steroid refractory ITP?
This is hard to answer in the absence of much more information about the patient. In a steroid refractory patient, it is important to understand why. This puts the patient immediately into a meeting refractory group (not responding to steroids). If there is an immediate need, IVIG is better. If the ...
Would you offer consolidation RT to a young woman with bulky mediastinal DLBCL who achieved early and persistent CR to RCHOP on PET?
Dr. @Dr. First Last has modestly omitted one salient trial in his answer, namely the Duke trial which he led evaluating low dose consolidation RT (20 Gy) following CR to induction chemotherapy, i.e. PET negative response (Kelsey et al., PMID 30858144). To recapitulate briefly, 62 patients with stage...
For patients receiving outpatient venetoclax/azacitidine who develop profound neutropenia with ANC <200, do you admit for monitoring during the nadir in the absence of fever?
I don't think I would admit these patients. My recommendation would be to monitor temperature daily or feel febrile and let the clinic know if they have any symptoms of localizing infection. The NCCN and IDSA guidelines talk that only neutropenic patients with fever, even amongst those who have the ...
Would you consider CAR-T therapy without autologous transplant in a patient with multiple myeloma whose best response to induction therapy is a partial response?
Excellent question that will be even more pressing in ~2024 (maybe earlier!) as we get more data and possibly more FDA/insurance approvals here. For now, the only way to get second-line CAR-T for inadequate response to frontline induction is on a clinical trial - and several such single-arm trials a...
How do you approach treatment for a patient with hypoplastic MDS who is not eligible for transplant?
I believe it is reasonable to try immunosuppressive therapy particularly if the patient is positive for HLA-DR15. I would treat such a patient with triple immunosuppressive therapy with horse ATG, cyclosporine, and eltrombopag (de Latour et al., PMID 34986284) if they are HLA-DR15 positive. If they ...