3. An 82-year-old woman is diagnosed with poor risk AML (complex karyotype), which appears to have arisen out of a prior myelodysplastic syndrome. She has multiple comorbidities and is limited in regards to her activities of daily living. She prefers to undergo some form of chemotherapy as long as she can tolerate it. Which treatment would you choose?
- Full-dose induction therapy with 7 and 3, to be followed by consolidation with intermediate-dose ara-C
- High-dose ara-C
- HYPOMETHYLATING AGENT
- Best supportive care
Sixty-seven percent of respondents chose the best route, the use of a hypomethylating agent. The advisory panel was somewhat taken aback that 24% of respondents chose to offer best supportive care, despite the fact the patient specifically requested undergoing some form of chemotherapy. This highlights the need for education regarding patient communication.
4. A 78-year-old woman presents with CLL (without del[17p]) with symptomatic enlarged lymph nodes and anemia due to bone marrow infiltration. She has COPD, which is treated with inhalers but otherwise well compensated. However, she also has atrial fibrillation on warfarin and high doses of metoprolol for rate control. Which treatment would you choose?
- OBINUTUZUMAB + CHLORAMBUCIL
Forty-five percent chose obinutuzumab + chlorambucil, considered the best treatment choice. Rituximab in this setting may also be a possibility, though it would have fairly limited efficacy. Given the patient’s cardiac complications, the choice of ibrutinib isn’t ideal given its association with potential bleeding and cardiac risks.11 Despite this, 28% of respondents still opted for this choice. FCR in this setting would be considered far too aggressive.
5. An 85-year-old female presents with right-sided and metastatic colon cancer that is not amenable to resection. Extended ras testing and braf testing show no mutations. She has a performance status of 1, hearing loss, and has had some falls at home in the past 6 months. Which of the following would be a reasonable approach?
- DO THE CARG TEST BEFORE DECIDING ON THERAPY
- DO THE CRASH TEST BEFORE DECIDING ON THERAPY
- Consult NCCN guidelines
- Proceed with full-dose folfox with Avastin and dose adjust depending on side effects
- Proceed with full-dose folfiri with panitumumab and adjust depending on side effects
While consulting the NCCN guidelines was overwhelmingly chosen, the advisory panel felt that this was in all likelihood a “cop out” answer, as reviewing the guidelines is technically never incorrect. Importantly, however, only 39% of respondents chose to do a CARG or CRASH test prior to deciding on therapy, highlighting the need for education around the utility of functional status tools.