Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
Do you recommend frontline bevacizumab with carbo/taxol in patients with advanced epithelial ovarian and BRCA mutation who will be receiving olaparib maintenance?
As shown in GOG-218, there is no apparent benefit to using concurrent bevacizumab with paclitaxel and carboplatin in the first-line setting, if this drug is not then continued during maintenance therapy. Our approach is to obtain genetic testing in patients with epithelial ovarian cancer as soon as ...
Are there scenarios that new visits/consults with patients can be done virtually amidst the COVID-19 outbreak?
Starting 3/16, we began offering lower-complexity / lower-risk patients the option of having a Tele-medicine consult vs re-scheduling to a later date. This offer has been extended broadly to all new consults at our facility when the provider indicates that s/he can extend comparable service virtuall...
Given the results of PORTEC-4A, what adjuvant therapy, if any, would you offer a patient with a POLE-mutant endometrial cancer who also has a p53 mutation and substantial (>5 foci) of LVSI?
When you have dual mutation, the better of the two mutations drives the outcome, so it would be treated like a POLE-type. If substantial LVSI and pathological nodal assessment are done, I would favor Brachy alone. If nodes are not assessed, I would favor EBRT. The link below has references about dua...
For early-stage vulvar cancer that is clinically/radiographically node negative with no surgical lymph node evaluation (e.g., patient or surgeon refusal), would elective nodal irradiation be reasonable in the absence of risk factors warranting treatment to the primary site?
It is tempting to skip elective nodal irradiation in this setting, especially if the radiographic evaluation includes a PET-CT, where the negative predictive value is probably close to 90%. However, if the risk of groin LN involvement is at least 15%, based on primary tumor characteristics such as s...
Would you consider modifying T&O fractionation during the COVID-19 pandemic?
We have been using 7gy x 4 instead of 5 fraction regimen in the past. A 2 fraction regimen showed lower local control in comparison to 4 fractions in the IAEA randomized trial.
Between KEYNOTE A-18 and INTERLACE, for which patients would you recommend using one protocol over another?
We currently favor A-18 for stage III disease (clinical or node-positive). A-18 had a more modern RT technique both for EBRT and brachytherapy while in INTERLACE, 60% had a prescription to point A for brachytherapy. In comparison with the EMBRACE 3D brachytherapy series, pelvic recurrence rate seems...
If blood counts are being checked during concurrent chemoradiation, is there a number at which point you would recommend a radiation treatment break?
I’ll let the platelets go as low as 10K before stopping. I lean heavily on the rate of decline to intervene with a break sooner than the absolute numbers if heading for trouble and later if decline is slow and at reaching the end of treatment.
What is your response to the question, "Is this terminal?"
Thanks for this question, it's really important. This question comes up in two distinct scenarios: when a person is first diagnosed and when a person is nearing the end of her life. Let's talk about them in sequence. 1). At diagnosis: When a person is first diagnosed, this question is part of "getti...