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...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?
Overall, evidence suggests that while SSRIs do increase the risk of bleeding. The absolute risk of a bleeding event remains low and is usually not serious. A 2017 meta-analysis by Laporte et al., suggested that overall bleeding risk is increased by at least 36% while other meta-analyses suggest that...
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 ...
In clearly resectable pancreatic adenocarcinoma with no arterial or venous involvement, is there a role for neoadjuvant chemotherapy?
There is currently equipoise regarding this question, and the Alliance A021806, a phase III trial evaluating perioperative versus adjuvant therapy for resectable pancreatic cancer, clinical trial will address it. There is a role in certain subsets of patients without clear vascular involvement regar...
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...