Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a patient with a T3 spindle cell metaplastic breast cancer?
This is a tough and controversial situation, and hard to reach a consensus due to the paucity of prospective data specifically focused on this subtype. The data available suggest that these tumors are less responsive to chemotherapy. Given these concerns for chemorefractoriness, I generally favor pa...
When would you offer anthracycline based adjuvant chemotherapy for a T1cN0 TNBC?
Taxotere/Cytoxan (TC) 4 cycles would be a more reasonable standard adjuvant choice with proven DFS and OS advantage over AC (Jones et al, JCO 2009), and would avoid the risk of cardiotoxicity from Adriamycin. The data was demonstrated in older as well as younger patients from that trial. AC-T would ...
What adjuvant therapy, if any, would you offer for a high-grade perivascular epithelioid cell (PEComa) tumor of the endometrium after R0 resection?
In the UK, no adjuvant therapy would be administered.
Would you place an IVC filter in a patient with an acute PE and an absolute contraindication for anticoagulation, but negative imaging for proximal DVT?
Good question. In this scenario, it would be reasonable to place an IVC filter. I would also image the IVC/pelvic veins in an effort to locate the origin of the embolus. A residual clot (depending on the size) may affect the approach to placement of IVC filter. Other variables include whether the PE...
Would you use maintenance avelumab for a patient with metastatic urothelial carcinoma who progressed on first-line pembrolizumab, then had stable disease after at least four cycles of second-line carboplatin plus gemcitabine?
Great question. I would suggest that if the patient progressed on prior PD-1/PD-L1 inhibition, the standard would be observation (as challenging as that may be in clinical practice!). At progression, would probably not offer checkpoint inhibitor and would instead favor novel therapies like enfortuma...
What is your preferred treatment approach for a patient who has prostate cancer with disease only in retroperitoneal nodes, experiencing rapid biochemical progression on abiraterone, and who was previously treated with an androgen receptor inhibitor while non-metastatic?
I would consider a non hormonal option for this patient. I advise germline/somatic testing to evaluate for DNA repair mutations that are present in 15-20% of the patients. If these are present, it identifies PARP inhibitor as an option. Rarely next generation sequencing may identify MSI-high disease...
For patients with cancer receiving a bone-modifying agent (bisphosphonate or denosumab) who suffer a fracture requiring stabilization or reconstruction, how do you manage the bone-modifying agent peri-operatively?
There’s been suggestion that administering bone-modifying agents may delay or impair fracture healing, but it has not been borne out by the literature. The half-life in bone is actually quite long so whether treatment interruption makes a difference is questionable. Also, since most patients receive...
How would you manage OCPs in a patient who develops a VTE while on treatment?
If a patient has a venous thromboembolic event, while on a combined estrogen-progesterone oral contraceptive, it is reasonable to continue the OCP with the initiation of anticoagulation. A study from 2016 revealed that it was safe to continue hormone therapy with the anticoagulation (Martinelli et a...
What are your thoughts on adding mycophenolate to steroids in the first line treatment of ITP based on the results of the FLIGHT trial?
This was an impressive study that should alter how upfront ITP is managed. The study was well designed, with randomization against the current standard of care. Efficacy was clear with HR for treatment failure of 0.37 (p=0.0029). What is also nice is that unlike TPO agonists which do not have define...
In a patient with high-risk gestational trophoblastic neoplasia, how would you approach treatment of recurrence at 6 months post EMA-CO?
NCCN guidelines recommend EMA-EP (etoposide, methotrexate, actinomycin-d alternating with etoposide and cisplatin) for patients who have recurrence after a complete response to EMA-CO. Given the pulmonary metastases, I would not recommend hysterectomy as initial therapy. However, if the patient had ...