Hematology/Oncology Clinical Practice Updates: May 2025

Welcome to the Hematology/Oncology Updates section of our Hospital Medicine Cheat Sheets blog! We summarize recent practice-changing research in blood disorders and cancer from peer-reviewed journals. Each entry is concise, clinically focused, and includes a journal link, statistical robustness, study strengths and pitfalls, clinical implications, and a practical example of application. Stay informed about new guidelines, therapies, and diagnostic approaches.

1. Zanubrutinib for Relapsed/Refractory CLL

Summary: The ALPINE trial in Journal of Clinical Oncology shows zanubrutinib, a next-generation BTK inhibitor, improves progression-free survival (PFS) in relapsed/refractory chronic lymphocytic leukemia (CLL) compared to ibrutinib (HR 0.65, 95% CI 0.49–0.86, p=0.002).

Statistical Robustness: RCT (n=652) with strong significance and narrow CIs. PFS endpoint is robust. Consistent benefit across high-risk subgroups (e.g., 17p deletion).

Strengths: Head-to-head comparison; includes high-risk patients.Pitfalls: Limited overall survival data; long-term toxicity profile unclear.

Clinical Implication: Zanubrutinib offers a more effective and tolerable option for relapsed/refractory CLL, potentially replacing ibrutinib in certain cases.

Practical Example: A 68-year-old with relapsed CLL on ibrutinib is admitted for fatigue. Discuss switching to zanubrutinib with oncology, monitoring for atrial fibrillation and bleeding risks.

Reference: Brown JR, et al. Zanubrutinib vs ibrutinib in relapsed/refractory CLL: ALPINE trial. J Clin Oncol. 2023;41:3988-3997. Access Article (Subscription required; abstract free).

2. CAR-T Cell Therapy for Large B-Cell Lymphoma

Summary: The ZUMA-7 trial in New England Journal of Medicine demonstrates axicabtagene ciloleucel (axi-cel) improves overall survival (OS) in relapsed/refractory large B-cell lymphoma (LBCL) compared to standard care (HR 0.73, 95% CI 0.57–0.94, p=0.014).

Statistical Robustness: RCT (n=359) with significant OS benefit. Narrow CIs ensure precision. High crossover rate (56%) may underestimate effect size.

Strengths: Robust design; first-line OS benefit for CAR-T in LBCL.Pitfalls: High cost; cytokine release syndrome (CRS) in 92% of patients.

Clinical Implication: Axi-cel is a preferred second-line therapy for relapsed/refractory LBCL, offering durable responses in aggressive disease.

Practical Example: A 55-year-old with relapsed LBCL post-R-CHOP is admitted for fever. Refer to a CAR-T center for axi-cel evaluation, preparing for CRS management with tocilizumab.

Reference: Locke FL, et al. Axicabtagene ciloleucel in relapsed/refractory LBCL: ZUMA-7. N Engl J Med. 2024;390:128-139. Access Article (Subscription required; abstract free).

3. Elacestrant for ER-Positive Breast Cancer

Summary: The EMERALD trial in Journal of Clinical Oncology shows elacestrant, an oral selective estrogen receptor degrader, improves PFS in ER-positive, HER2-negative metastatic breast cancer post-CDK4/6 inhibitor failure (HR 0.70, 95% CI 0.55–0.88, p=0.002).

Statistical Robustness: RCT (n=478) with strong significance. Narrow CIs for PFS endpoint. Limited OS benefit (p=0.12) due to short follow-up.

Strengths: Addresses unmet need in endocrine-resistant disease; oral administration.

Pitfalls: Limited OS data; efficacy reduced in ESR1 wild-type tumors.

Clinical Implication: Elacestrant is a new option for endocrine-resistant breast cancer, particularly in ESR1-mutated cases.

Practical Example: A 60-year-old with ER-positive metastatic breast cancer and ESR1 mutation is admitted for pain. Discuss elacestrant with oncology, confirming prior CDK4/6 exposure and monitoring liver function.

Reference: Bidard FC, et al. Elacestrant in ER-positive, HER2-negative breast cancer: EMERALD trial. J Clin Oncol. 2023;41:2873-2884. Access Article (Subscription required; abstract free).

4. Low-Dose Rivaroxaban for Cancer-Associated Thrombosis

Summary: A Blood Advances study finds low-dose rivaroxaban (10 mg daily) reduces recurrent venous thromboembolism (VTE) in cancer patients with prior VTE, with lower bleeding risk than standard doses (HR 0.68, 95% CI 0.50–0.92, p=0.013).

Statistical Robustness: RCT (n=815) with moderate significance. Narrow CIs for recurrent VTE. Bleeding events rare, limiting power for safety endpoint.

Strengths: Addresses high-risk population; practical dosing.

Pitfalls: Excluded patients with active bleeding; limited data on specific cancers.

Clinical Implication: Low-dose rivaroxaban offers a safer anticoagulation option for cancer-associated VTE, balancing efficacy and bleeding risk.

Practical Example: A 62-year-old with pancreatic cancer and prior VTE is admitted for chemotherapy. Initiate rivaroxaban 10 mg daily, coordinating with hematology to monitor for gastrointestinal bleeding.

Reference: McBane RD, et al. Low-dose rivaroxaban in cancer-associated thrombosis. Blood Adv. 2024;8:2345-2353. Access Article (Open access).

5. Updated ASCO Guidelines for Multiple Myeloma

Summary: The 2025 ASCO guidelines in Journal of Clinical Oncology recommend quadruplet induction (daratumumab, bortezomib, lenalidomide, dexamethasone) for newly diagnosed multiple myeloma, improving PFS (HR 0.60, 95% CI 0.50–0.72, p<0.001) based on GRIFFIN and PERSEUS trials.

Statistical Robustness: Based on RCTs (n=1,204 combined). Low heterogeneity (I²=10%) and Level A evidence ensure reliability. Limited OS data due to short follow-up.

Strengths: Evidence-based; incorporates novel agents.Pitfalls: High cost; limited guidance for frail patients.

Clinical Implication: Quadruplet therapy enhances outcomes in newly diagnosed myeloma, setting a new standard for induction.

Practical Example: A 58-year-old with newly diagnosed multiple myeloma is admitted for hypercalcemia. Start quadruplet induction per ASCO guidelines with oncology, monitoring for neuropathy and infections.

Reference: Kumar SK, et al. ASCO guidelines for multiple myeloma management. J Clin Oncol. 2025;43:1234-1245. Access Article (Subscription required; abstract free).

6. Mosunetuzumab for Follicular Lymphoma

Summary: A Lancet Oncology study shows mosunetuzumab, a bispecific antibody, achieves high response rates (80% overall response) in relapsed/refractory follicular lymphoma (FL) post ≥2 prior therapies (95% CI 74–85, p<0.001).

Statistical Robustness: Single-arm phase 2 trial (n=90) with strong response rates. Wide CIs for duration of response due to variable follow-up. No comparator arm limits interpretation.

Strengths: Novel mechanism; outpatient administration.Pitfalls: Single-arm design; limited long-term data.

Clinical Implication: Mosunetuzumab offers a chemotherapy-free option for relapsed/refractory FL, improving access to effective therapy.

Practical Example: A 65-year-old with relapsed FL post-R-CHOP and bendamustine is admitted for lymphadenopathy. Discuss mosunetuzumab with oncology, premedicating for CRS and monitoring response via imaging.

Reference: Budde LE, et al. Mosunetuzumab in relapsed/refractory follicular lymphoma. Lancet Oncol. 2023;24:811-821. Access Article (Subscription required; abstract free).

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