Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage high-risk MDS IB2 patients on HMA and venetoclax who develop an acute stroke requiring antiplatelet therapy?
Not sure of the current platelet count? Not sure of the age of the patient.Will still use antiplatelet therapy for acute stroke as advised.Support with platelet transfusion as needed for platelet count <20. Hopefully patient responds to HMA and venetoclax, and platelet counts improve.If in CR by mar...
How would you manage aplastic anemia refractory to multiple agents?
If indeed the patient has been treated with all reasonable alternatives to BMT, the choices are 1) watch and wait with supportive care or 2) bone marrow transplantation. I understand the reluctance of transplanting someone in their 70s with aplastic anemia; however, we do this routinely in patients ...
Would you recommend 10 years instead of 5 years of tamoxifen in a premenopausal woman with early stage, node negative ER/PR/HER2 positive breast cancer?
Both the ATLAS and aTTom randomized controlled trials demonstrated that 10 years compared to 5 years of tamoxifen improves disease-free and overall survival among women with hormone receptor-positive early stage breast cancer. Most of the benefit was seen in the decrease in late breast cancer recurr...
How would you treat a young man with a history of stage IA testicular pure seminoma s/p radical orchiectomy who has a solitary left inguinal lymph node recurrence and normal tumor markers?
Relapse in an inguinal node is somewhat unusual in testicular cancer unless there has been prior scrotal violation or surgery for maldescent. Trans-scrotal biopsy of the testis is usually an incorrect approach, as it can cause a different pattern of spread (to the inguinal nodes). Thus, I would not ...
What is your preferred neoadjuvant chemotherapy regimen for borderline resectable pancreatic ductal adenocarcinoma?
Agree while guidelines for the use of adjuvant therapy in resected PDAC are stronger (6 mos therapy for T1N0 tumors or greater), those for the use of neoadjuvant therapy are less clear. Some guidelines recommend not to use NAT unless there is a radiographic interface with mesenteric vessels, or in t...
How long do you give neoadjuvant therapy in resectable/borderline resectable pancreatic cancer, when you are considering chemoradiotherapy as part of your neoadjuvant strategy?
I would aim for at least 6 cycles. A recent large study from Mayo Clinic evaluated 194 patients with borderline resectable or locally advanced pancreatic adenocarcinoma treated with neoadjuvant chemotherapy followed by concurrent chemoradiation therapy. 94% of patients had an R0 resection.Only 3 fac...
What dose and formulation of GnRH agonist do you use for ovarian suppression in young breast cancer patients?
Available data is largely with the monthly formulation. I don't have a strong preference for which LHRH agent (though some payers might). The q12-week depot formulation may not maintain full suppression for younger patients. Here is my pragmatic strategy Start with monthly (q4 week). If not tolerat...
Under what circumstances do you give chemotherapy for a nondiagnostic pancreas biopsy that is suspicious for adenocarcinoma?
Assuming it is a localized pancreatic abnormality and no "metastases," I would not give chemotherapy as such. If anything, I would consider surgical removal, which will also give the exact diagnosis. To start, chemotherapy is not curative (maybe if it were a lymphoma!). There may be some way of doin...
Would the presence of only mature teratoma on orchiectomy specimen lead you to consider upfront RPLND followed by adjuvant chemotherapy as opposed to upfront chemotherapy in a patient with bulky para-aortic nodal disease (cN3) and AFP/beta-HCG elevation?
If there is an elevated AFP or hCG, then by definition, he has metastatic germ cell cancer and needs chemo initially, followed almost certainly by post-chemo RPLND done by a skilled and experienced urologist.
How would you approach adjuvant therapy for large (≥4 cm), node negative, HR+, HER2- breast cancer in an elderly woman with comorbidities including neuropathy?
If multiple co-morbidities are present in an elderly patient with locally advanced HR+/HER2- breast cancer that precludes anthracycline and taxane chemotherapy regimen, then I would consider 2 options: (1) CMF regimen which is active and generally well tolerated (one can also consider upfront dose r...