Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach systemic therapy in a postmenopausal female with previous early stage ER/PR positive IDC, on anastrozole, with new isolated metastatic disease that remains strongly ER/PR positive?
For the typical patient with disease recurrence (and measurable or evaluable disease) on adjuvant AI, the standard of care would be to switch endocrine therapies, usually from the AI to fulvestrant, and add a CDK 4/6 inhibitor, though simply adding the CDK 4/6 inhibitor to the AI would also be reaso...
What is your approach to further work-up and management of neutropenia in patients with SLE/RA overlap?
This is an interesting situation that comes up in the routine evaluation of patients with rheumatoid arthritis and other autoimmune syndromes. The normocellular bone marrow suggests a peripheral destruction, in general, and raises some concerns for antibodies directed against neutrophils. These are ...
How would you treat an LGL leukemia patient who has been refractory to treatments with cyclosporine, MTX, and cyclophosphamide?
In my experience, true refractoriness to methotrexate and cyclophosphamide is unusual in LGL. What is more usual is that patients take a long time to respond and I usually don’t change therapy before a full 6 months trial of either agents. That is also what the published data suggests. In the meanwh...
How would you treat an LGL leukemia patient who has been refractory to treatments with cyclosporine, MTX, and cyclophosphamide?
In my experience, true refractoriness to methotrexate and cyclophosphamide is unusual in LGL. What is more usual is that patients take a long time to respond and I usually don’t change therapy before a full 6 months trial of either agents. That is also what the published data suggests. In the meanwh...
Would you consider giving hormone replacement therapy to a patient with atypical ductal hyperplasia with no alternative options to manage postmenopausal symptoms?
After careful counseling about the possible risks and symptomatic benefits of hormone replacement therapy (HRT), I do prescribe these supplements when requested by my patients with ADH and DCIS. This is particularly true for women who have had hysterectomy, where the progestational component of HRT ...
How do you manage a patient with sickle cell disease during pregnancy?
I refer all pregnant women with SCD to maternofetal medicine/high risk pregnancy clinic for more frequent monitoring. I recommend a baby aspirin for preeclampsia prevention (see UK guidelines). I recommend folic acid 4 mg. If they do have iron overload, I do not recommend iron supplementation. For a...
How do you manage endocrine therapy for premenopausal women with breast cancer who are heterozygous for factor V Leiden but have no history of thrombosis?
This is a difficult situation given that the literature is contradictory on this topic. Both tamoxifen and a factor V Leiden mutation independently increase risk of thromboembolic events. It is unclear whether, together, they would be additive in conferring risk of thrombosis. Dr. Cuzick wrote a ver...
How do you manage endocrine therapy for premenopausal women with breast cancer who are heterozygous for factor V Leiden but have no history of thrombosis?
This is a difficult situation given that the literature is contradictory on this topic. Both tamoxifen and a factor V Leiden mutation independently increase risk of thromboembolic events. It is unclear whether, together, they would be additive in conferring risk of thrombosis. Dr. Cuzick wrote a ver...
What systemic therapy would you use in patients with gastric cancer who had a relapse after Durva-FLOT (MATTERHORN regimen)?
In the rapidly evolving era of more intensive perioperative therapy, the FLOT-durvalumab combination is quickly becoming the standard for good-performance patients who can tolerate triplet chemotherapy and have no contraindications to immunotherapy. What to do after recurrence will depend in part on...
Would you recommend PARP inhibitor maintenance for a BRCA wild-type, HRD+ advanced ovarian cancer?
We have a better understanding of ovarian cancer biology now, including the importance of germline and somatic BRCA mutations, as well as the role of homologous recombination deficiency (HRD) in tumors and the potential benefit of new therapies in the maintenance.Considerations for maintenance thera...