Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred first line regimen for myeloma with severe renal impairment, either on or off dialysis?
In general, for patients with renal insufficiency related to their myeloma, time is nephrons. So the earlier you can correct the hypercalcemia, lower circulating uric acid, stop ongoing bad behaviors (NSAID overuse, etc), and treat the myeloma, the better. If the patient is admitted, I will give pa...
Which, if any, young/fit intermediate-risk AML patients would you not offer allogeneic transplant to in MRD- CR1?
At our center, we routinely offer the option of allogeneic stem cell transplant to younger fit patients with intermediate and poor risk AML. The only individuals that we would not offer this to are those with biallelic CEBPalpha mutant AML or NPM1 mutant/FLT3 wildtype AML without a matched sibling d...
Are there any differences in your approach to therapy for secondary versus primary myelofibrosis?
Good question. I will risk stratify patients with secondary MF using the MYSEC-PM score and primary MF patients using DIPSS+ or MIPSS. Anecdotally, patients with secondary MF tend to have more indolent MF and there is definitely a grey zone period when you know they are transforming but still doing ...
How soon do you anticipate response to cyclosporine in red cell aplasia and what cyclosporine trough levels do you target?
I typically use tacrolimus rather than cyclosporine. I find it has fewer off target effects and is easier to maintain blood levels. Trough blood level is 5-10. Cyclosporine levels are 100-400 which is too broad. I would give it at least 3 months. If not done already, I would do for LGL.
What is your approach to using medications that can cause bone marrow suppression in SLE patients who have persistent leukopenia?
I am so glad someone asked this question. I have heard some peers state that they are reluctant to use immunosuppressants in this situation. However, I do not agree with this. The whole reason our systemic lupus (SLE) patients have leukopenias is due to their autoimmunity (but make sure drugs, infe...
How do you approach anticoagulation in the setting of HIT and thrombocytopenia?
This is a very relevant but rather broad question. On a day-to-day basis, the decision on whether one is dealing with HIT vs other causes of thrombocytopenia can be complex. Applying the 4Ts score is easier in retrospect, but in real life patient management, the score has the potential to change alm...
If a patient had a grade 2 infusion reaction to initial dose of IV Rituximab, can you give subcutaneous Rituximab for cycle 2 or continue with IV Rituximab?
I would likely continue IV rituximab until no more infusion reactions are observed before switching to SQ.
How do you prepare patients with DLBCL on the potential need for cellular therapies after progression on first line regimens?
Once a patient is identified by the lymphoma team, they are referred to our cellular therapy service for full evaluation and discussion of CAR T cell risks, benefits, and logistics. The discussion of protocol versus commercial product, chemotherapy side effects versus CRS/ICANS, and severity includi...
Would you add Daratumumab to upfront treatment of multiple myeloma in a patient with tetraploidy on FISH?
I think the shortest answer is, "Do what you do for your patients with high-risk cytogenetics." If you ask 4 different myeloma specialists, you'll get 4 different answers: VRd for everyone, Dara-VRd for everyone, KRd just for high-risk, Dara-KRd just for high-risk... and then some (not me) will reco...
Is an elevated CRP an expected finding in an otherwise healthy patient with hemoglobin S - alpha thalassemia?
If you Google "CRP levels in sickle cell disease", you will find a number of articles reporting that CRP levels are chronically elevated in many patients with SCD. This undoubtedly reflects the chronic inflammatory state that is part of the clinical milieu of SCD. Patients with Sickle - alpha thalas...