Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you qualify and treat a patient with neutropenia, anemia, and abnormal NK cell population with normal trilineage marrow maturation?
I would run a molecular test to confirm that the clonality does not show a CD8-positive clone, as that is more common in LGL. The findings of a clonal NK population by flow cytometry would be enough, in the setting of neutropenia and anemia, to consider a diagnosis of NK cell LGL.
How do you choose between azacitidine and decitabine when deciding to treat a patient with MDS with a hypomethylating agent?
The only agent to prolong overall survival in patients with MDS is azacitidine so this is always my first choice particularly in older individuals at higher risk for complications of myelosuppression occurring at a higher rate with decitabine. Other issues to consider include ease of administration ...
Would you prescribe an aromatase inhibitor prophylactically for a post-menopausal woman with a deleterious BRCA2 mutation and a history of DCIS who declines prophylactic mastectomy?
The IBIS II trial (Lancet Onc Forbes et al 2016) established anastrazole was non inferior but not superior in preventing recurrences after DCIS. The MAP3 trial (Goss NEJM) demonstrated efficacy of extemestane vs tamoxifen in the chemoprevention of a first breast cancer in higher risk postmenopausal ...
When treating a patient with colon cancer with adjuvant FOLFOX, in what situation, if any, would you consider removing the 5-FU bolus empirically?
I'm not aware of any data that clearly indicate how much the 5-FU bolus really adds to the therapeutic efficacy of infusional 5-FU regimens. I think the benefit (if any) is likely to be very small. That being said, if I'm treating a patient with curative intent, I don't drop the 5-FU bolus unless co...
For localized esophageal cancer in patients with preexisting neuropathy, what do you use concurrently with radiation therapy?
I would probably start with low-dose carboplatin and paclitaxel as done in the CROSS trial, and monitor carefully for worsening neuropathy with weekly assessment. As the doses are low and the duration of therapy limited to only 5 weeks, we may not see much worsening. In CROSS, there was 15% neurotox...
Would you consider using Tamoxifen instead of an AI in a post-menopausal women with ER+ and/or PR+ breast cancer who can't/won't discontinue hormone replacement therapy?
I use tamoxifen in a switching strategy in many postmenopausal women anyway so the short answer is yes. The longer answer is that the ongoing use of HRT in this setting has issues that aren't solved by whether you use a SERM or an AI.
How would you approach the management of small, mutli-focal gastric NET?
Gastric carcinoid tumors are categorized into types 1, 2, or 3. Type 1 occurs in the setting of autoimmune atrophic gastritis. Type 2 is Zollinger Ellison syndrome. Type 3 is sporadic. I would recommend checking a gastrin level, B12, iron and ferritin. Endoscopic evaluation and mapping biopsies. Tre...
Do you use bevacizumab in patients with history of VTE (DVT/PE) who are stable on anticoagulation?
I have used bevacizumab in many patients who are stable on therapeutic anticoagulation for prior VTE. If the first VTE occurs during treatment with bevacizumab, I hold the drug and then consider restarting it (if warranted by the clinical situation) after a period of stability on therapeutic anticoa...
Given more restrictions on later line PARP inhibitor use for patients by BRCA status, would you consider repeat biopsy with somatic testing to identify candidates for second line maintenance therapy following platinum treatment for a patient who is gBRCAwt?
I would be comfortable deciding on the use of PARP maintenance in the second line based on initial somatic testing and would not feel a need to rebiopsy. Additionally, olaparib still has an indication for BRCAwt patients for maintenance post frontline regardless of biomarker status. Disclosure: No...
How do you manage a patient with gastric/GE junction carcinoma who has positive lymph nodes at resection after neoadjuvant chemotherapy?
So, we know from the review of the MAGIC study by Dr. Smyth that ypN+ tumors are associated with a worse prognosis than ypN0 tumors. However, there doesn't seem to be anything we can clearly do about it with standard options:1) Changing chemotherapy is not likely to be helpful. Phase III studies in ...