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Best podcasts about Asco

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Latest podcast episodes about Asco

ASCO Guidelines Podcast Series
Chemotherapy and Targeted Therapy for HER2-Negative Metastatic Breast Cancer that is Either Endocrine-Pretreated or Hormone Receptor–Negative: ASCO Guideline Rapid Recommendation Update

ASCO Guidelines Podcast Series

Play Episode Listen Later Aug 4, 2022 8:47


An interview with Dr. Beverly Moy from Massachusetts General Hospital in Boston, MA, lead author on "Chemotherapy and Targeted Therapy for HER2-Negative Metastatic Breast Cancer That is Either Endocrine-Pretreated or Hormone Receptor-Negative: ASCO Guideline Rapid Recommendation Update." Dr. Moy reviews data from the recently published DESTINY-Breast04 study, and the ASCO Expert Panel's updated recommendation on the use of trastuzumab deruxtecan. For more information, visit www.asco.org/breast-cancer-guidelines.   TRANSCRIPT Brittany Harvey: Hello, and welcome to the ASCO Guideline podcast series brought to you by the ASCO podcast network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today I'm interviewing Dr. Beverly Moy from Massachusetts General Hospital in Boston, Massachusetts, lead author on 'Chemotherapy and Targeted Therapy for HER2-Negative Metastatic Breast Cancer That is Either Endocrine-Pretreated or Hormone Receptor-Negative: ASCO Guideline Rapid Recommendation Update'. Thank you for being here, Dr. Moy. Dr. Beverly Moy: It's my pleasure. Thank you for having me. Brittany Harvey: Great. First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO Conflict of Interest Policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Moy, do you have any relevant disclosures that are directly related to this guideline topic? Dr. Beverly Moy: I do not have any relevant disclosures that are directly relevant to this guideline topic. Brittany Harvey: Thank you. Then let's talk about this rapid update. So first, what prompted a rapid update to this guideline on chemotherapy and targeted therapy for patients with HER2-negative metastatic breast cancer that is either endocrine-pretreated or hormone receptor-negative, which was last updated in 2021? Dr. Beverly Moy: First, I would state that ASCO issues rapid guideline recommendation updates when really important advances in the treatment and management of cancer have been presented. This mechanism really allows clinicians to keep up with the rapid advances in cancer management. The fact that a rapid update had to be issued just one year after the full updated guideline that was published in 2021, as you just mentioned, is really a testament to the advances in cancer research and clinical trials that have been made recently. But I will state that the reason why this rapid update was done was because the result of the DESTINY-Breast04 study were so strong and compelling and showed such a large degree of benefit to a large group of metastatic breast cancer patients that we felt as the guideline panel that this rapid update had to be out there. We really wanted to make sure that the oncology community was aware of these results. That's based on the strength of the trial. The DESTINY-Breast04 trial was a very large randomized study that showed that trastuzumab deruxtecan significantly improved progression-free survival and overall survival compared to treatment of physician's choice in patients with metastatic, “HER2-low” breast cancer. Brittany Harvey: So then based off this new data from the DESTINY-Breast04 trial that you just mentioned, what is the updated recommendation from the guideline expert panel? Dr. Beverly Moy: So the updated recommendation is that patients with HER2-low, or to be specific, HER2 IHC1+ or 2+ and ISH negative metastatic breast cancer who have received at least one prior chemotherapy for metastatic disease, if they're hormone receptor-positive, are refractory to endocrine therapy, those patients should be offered treatment with trastuzumab deruxtecan. Brittany Harvey: And then what should clinicians know as they implement this new recommendation for trastuzumab deruxtecan? Dr. Beverly Moy: I think that there are a few things that clinicians really need to be aware of. One is that it significantly improved progression-free survival and overall survival, and that's pretty important. The paper was published in the New England Journal of Medicine, and folks can refer to that study specifically. But to be specific, it improved progression-free survival at a median follow-up of about 18 months from 9.9 months with trastuzumab deruxtecan compared to 5.1 months with treatment of physician choice in the entire study population. Median overall survival was 23.4 months with trastuzumab deruxtecan and 16.8 months with treatment of physician's choice. So that's really a marked improvement in both of those outcomes. It is also important to note that trastuzumab deruxtecan has a very important side effect, and that's the potential of developing drug-related interstitial lung disease or pneumonitis. And that could be very serious. This side effect was confirmed in about 12% of the patients who received trastuzumab deruxtecan, and about 1.3% of patients actually had severe symptoms requiring oxygen, and three patients in the study, so less than 1% actually died of this side effect. So that's something that needs to be monitored for very carefully, and clinicians need to be very cognizant of this potential side effect when using this drug. Brittany Harvey: Thank you for reviewing both the impact on survival and then the adverse event of interstitial lung disease. So how does this guideline update impact patients with breast cancer? Dr. Beverly Moy: So metastatic breast cancer is incredibly common. And this HER2-low, and I say, “HER2-low” because this is a definition that has never been made before. The patients with HER2 IHC1+ or 2+ and ISH negative disease, that's a very large group of patients. That's a lot of patients. So it's really important that this guideline is going to impact a very large group of patients. Again, it's those who've had at least one prior line of chemotherapy in the metastatic setting. And if they had hormone receptor-positive disease, it has to be refractory to endocrine therapy. But that's a lot of patients. And the results of this randomized study do show that trastuzumab deruxtecan is superior to other treatment of physician's choices that were available before this study came out in terms of its efficacy. So this guideline is very significant for clinicians and metastatic breast cancer patients across the world. Brittany Harvey: Definitely. It's great to have a new option and one that has such a great clinical impact for patients. So then finally, Dr. Moy, what are the outstanding questions regarding chemotherapy and targeted therapy for HER2-negative metastatic breast cancer? Dr. Beverly Moy: I think like any good study, this raises a lot of other important questions. Again, this HER2-low definition that I described is an interesting one. It's a very large bucket of patients. One obvious question is, would this drug be as effective in patients who are truly HER2-negative, so HER2 IHC of 0? Kind of, overnight, the results of this study has changed the paradigm for many oncologists because we used to just say HER2-positive or HER2-negative. And now we're looking back at patients' charts to see what their immunohistochemistry results were. Does it really matter if it's IHC 0 or 1+ or 2+? So that would be very interesting. Another outstanding question is: what about the use of trastuzumab deruxtecan earlier in the treatment? I said that it should be offered for patients who've received at least one prior line of chemotherapy? What about first line chemotherapy in the metastatic setting? And there are multiple studies studying this drug in actually early stage breast cancer as well. So lots of unanswered questions about this compound that's pretty remarkable. Brittany Harvey: Great. Well, I want to thank you so much for your time today, Dr. Moy, for discussing the results of the DESTINY-Breast04 trial with me, and for your work to rapidly update this guideline. Thank you so much. Dr. Beverly Moy: Thank you, Brittany. It was a pleasure. Brittany Harvey: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/breast-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in iTunes or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  

SBOC
Produção científica brasileira no ASCO 2022

SBOC

Play Episode Listen Later Aug 3, 2022 61:24


Dr. Alexandre Jácome, diretor da Escola Brasileira de Oncologia, e Dr. Jorge Sabbaga, editor-chefe do Brazilian Journal of Oncology, conversam com autores brasileiros que tiveram seus trabalhos expostos no Congresso da American Society of Clinical Oncology (ASCO) de 2022, o principal fórum da especialidade no mundo. São eles: Dr. Diogo Bastos, Dr. Bernardo Garicochea, Dra. Camilla de Rebouças, Dr. Bruno Teixeira e Dr. Andrey Soares. Ouça já!

The ASCO Post Podcast
ASCO 2022: Conversations in Lung Cancer

The ASCO Post Podcast

Play Episode Listen Later Aug 2, 2022 16:37


On this episode, we're featuring discussions on lung cancer that took place at the 2022 ASCO Annual Meeting. They were led by Dr. Gilberto de Lima Lopes, Jr, of the Sylvester Comprehensive Cancer Center at the University of Miami. The first focuses on data from a study of a novel bispecific antibody in patients with non–small cell lung cancer that exhibits the MET exon 14 skipping mutation. The second focuses on an analysis of patients with lung cancer treated with chemoimmunotherapy regimens.To listen to more podcasts from ASCO, visit asco.org/podcasts.

OncLive® On Air
S7 Ep19: Research Reflections: Subbiah Reviews Striking ASCO 2022 Data Across Oncology

OncLive® On Air

Play Episode Listen Later Aug 1, 2022 12:20


Dr Subbiah discusses findings from 4 presentations that stood out to him from the 2022 ASCO Annual Meeting: phase 2 data (NCT04165772) demonstrating a 100% complete response rate in 12 patients with mismatch repair–deficient, locally advanced rectal cancer who received dostarlimab (Jemperli); DESTINY-Breast04 (NCT03734029), results he called “important and practice changing” for patients with HER2-low unresectable and/or metastatic breast cancer; a first-in-human study (NCT04585750) of PC14586, a novel agent targeting mutated TP53 in advanced solid tumors; and the LIBRETTO-001 trial (NCT03157128), which demonstrated that selpercatinib (Retevmo) can target RET-positive fusions in solid tumors.

Our MBC Life
S04 E18 - Report Back from ASCO 2022: What's the Latest in MBC Research?

Our MBC Life

Play Episode Listen Later Jul 29, 2022 68:42


The biggest cancer conference in the world,  the American Society of Clinical Oncology (ASCO) 2022 annual meeting, was back in person after 2 years online during the COVID pandemic. Some of the research highlights presented this year are “practice-changing.” and received a rarely given standing ovation. What is  practice changing in MBC?  Get the answer to this  question and a lot more in the report back from ASCO.Just like the conference itself, the report back from ASCO has become an annual event and a tradition at SHARE.  Shortly after the conference the co-producers of the Our MBC Life podcast Natalia Green and Victoria Goldberg welcomed Dr Niel Iyengar to SHARE to talk about the main highlights in Metastatic Breast Cancer from 2022 ASCO. Thanks for listening!More info is available in our episode notes for this series on our website:  www.ourmbclife.orgGot something to share? Feedback?Email: ourmbclife@sharecancersupport.org Send us a voice recording via email or through speakpipe on our website.  Follow us on Facebook, Instagram, and Twitter @ourmbclife 

The ASCO Post Podcast
ASCO 2022: Conversations in Breast Cancer

The ASCO Post Podcast

Play Episode Listen Later Jul 29, 2022 13:41


At the 2022 ASCO Annual Meeting, Dr. Ann Partridge, of Dana-Farber Cancer Institute, discussed trends in breast cancer with several colleagues. On this episode, we're featuring two of those conversations: one on antibody-drug conjugates, and another on endocrine therapy plus ribociclib for progressive breast cancer.To listen to more podcasts from ASCO, visit asco.org/podcasts.

MOC Brasil
#217_Pós-ASCO 2022 | Eficácia e segurança de trastuzumabe biossimilar no câncer de mama

MOC Brasil

Play Episode Listen Later Jul 29, 2022 7:37


Durante o congresso anual da Sociedade Americana de Oncologia Clínica (ASCO 2022), foram apresentados os resultados preliminares de um importante estudo brasileiro multicêntrico observacional prospectivo de mundo real envolvendo o uso de trastuzumabe biossimilar no tratamento do câncer de mama HER-2 positivo no cenário adjuvante. Para falar sobre o estudo e a importância dos medicamentos biossimilares na redução de custos do tratamento oncológico, preparamos este vídeo exclusivo, com participação da Dra. Debora Gagliato e do Dr. Romualdo Barroso-Sousa.

ASCO Daily News
A Novel Approach to Address Financial Toxicity

ASCO Daily News

Play Episode Listen Later Jul 28, 2022 13:14


Host Dr. John Sweetenham, of the UT Southwestern's Harold C. Simmons Comprehensive Cancer Center, and Dr. Bridgette Thom, of the Memorial Sloan Kettering Cancer Center, discuss a novel intervention to address financial toxicity and social need using the Electronic Medical Record.   TRANSCRIPT Dr. John Sweetenham: Hello. I'm Dr. John Sweetenham, the associate director for clinical affairs at UT Southwestern Harold C. Simmons Comprehensive Cancer Center and host of the ASCO Daily News podcast. My guest today is Dr. Bridgette Thom, a researcher at Memorial Sloan Kettering (MSK) Cancer Center. We'll be discussing a novel approach to address financial toxicity that uses the electronic medical record to streamline referrals to financial assistance and counseling for high-risk patients. Our full disclosures are available in the show notes, and disclosures of all guests on the podcast can be found on our transcripts at asco.org/podcasts. Dr. Thom, it's great to have you on the podcast today. Dr. Bridgette Thom: Thanks so much for having me. Dr. John Sweetenham: Dr. Thom, the high costs of cancer care have caused major financial distress for many patients and their families. And this, of course, has been the subject of a great deal of literature in recent years. As you noted in your poster presentation at the recent ASCO Annual Meeting, there are limited interventions, despite a need for patient level and system-based solutions (Abstract 6596). Listeners to our podcast will remember a previous discussion that we had with Dr. Derek Raghavan from the Levine Cancer Institute, where they had instituted financial toxicity grand rounds to partially address this problem. Can you tell us about the novel approach that you and your colleagues explored using the electronic medical record to streamline referrals for financial assistance and counseling? Dr. Bridgette Thom: I first have to credit our team for this work. Dr. Emeline Aviki, who is a gynecological surgical oncologist with keen interest in affordability and payment models, founded the MSK affordability working group several years ago. The first priority of the group was to determine the scope of financial hardship at our institution. At the time, we were absent a systematic screening process. So she, our data analysts, and representatives from our Patient Financial Services Program, developed proxy measures to figure out which patients might be having financial issues. Looking through the medical record, we found those patients who had used one of our Patient Financial Services assistance programs, those who had billing issues, and those who had been referred specifically to social work for a financial issue. And in doing so, we found out that about 25% of our patients over a 2-year period were facing some sort of financial issue. Looking closer at that data, patients experiencing financial hardship weren't necessarily being connected to the resources that we had available, which include copay assistance programs, financial assistance programs, and support for non-medical essential needs. So, for example, we had about 1 in 6 patients who had some sort of payment issue, but only about 20% of them had applied for financial assistance. And we wanted to figure out why this was happening and review the process. In doing so, we discovered that too much burden was being placed on already burdened social workers who had to triage all those issues. So Dr. Aviki in her wisdom realized that care providers, physicians, advanced practice providers (APP), nurses needed to make direct referrals to the resources that we had. So we had a place for patients to go, we just needed an easier mechanism for them to get there. And that was the birth of the financial toxicity order set. And she and her team really powered through the developmental and testing phases working with IT, our strategy administration groups, clinical end users, our PFS team, that's Patient Financial Services. We built this order set that allows clinicians directly to refer to our resources. So clinicians, either through their discussions with patients or if patients bring up an issue, through the order set they can select a reason for a referral, the urgency of referral, the clinical location, etc. And then those orders go directly to our Patient Financial Services staff who then contact patients. We piloted this program in late 2020, early 2021 on 1 service, and then used that feedback to roll out the program first to our outpatient clinics and then to inpatient. That process involved a lot of educational efforts, getting the word out, and working with IT and our strategy team to stay on top of the data and monitor referrals over time. Dr. John Sweetenham: Thanks. Could you say just a little bit more about the educational process that you use? I noticed in looking at your poster that the bulk of referrals came either from the clinic nurse or from the APP. Did you tailor your education in any way to the specific provider that was involved? How did you do that piece? Dr. Bridgette Thom: Our affordability working group is an interdisciplinary team and we have nurses, social workers, physicians. So we did a lot of grand rounds work tailored to the audience be it by disease type or clinical role. Dr. John Sweetenham: Great, thank you. This is clearly great work. There's a lot of useful and helpful information in your abstract and in your poster. What would you say are the key takeaways from the intervention? What would you say about the scalability of this approach into community practice as opposed to a very large institution such as yours? Dr. Bridgette Thom: One key takeaway from a process perspective was the need, like I said, for an interdisciplinary approach to handling the issues. That might seem obvious, but it was really crucial to the success of the project to engage key departmental stakeholders and decision makers very early in the process and keep them informed throughout the development of the order set. That definitely helped us to smooth a potentially bumpy road when we're dealing with big systems change. From an outcomes perspective, a key takeaway is the importance of having actionable items to empower the care providers. So while our institution has this amazing program, our Patient Financial Services program which provides counseling, and connects patients to tangible resources, this type of intervention I think could be scalable or applicable to a community practice or smaller hospital, provided there's somebody, a social worker, patient navigator, [or] nurse, that can be a connection for patients and those potential resources that do exist out there. For us going forward, we're going to continue to evaluate the order set, both from the clinical end user and then also the Patient Financial Services staff to learn more about their perspectives and what can be adapted in the order. We also, of course, want to learn from our patients about their experience with the process, and so we have projects, both research and program evaluation, in the works to consider their perspective. Dr. John Sweetenham: Great, thank you. And I guess 1 of the other aspects of this where there is obviously substantial opportunity is that, of course, currently, you're still reliant upon the provider to place the order. And I wonder whether you feel that some form of screening for social need and financial hardship could be embedded within the electronic health record as a key next step, so that you proactively identify those high-risk patients. Dr. Bridgette Thom: Definitely. And that is, in fact, our next step. We are currently piloting our financial hardship screening tool on 4 large services at our institution. The objective here is to, like you said, proactively identify patients who might be at risk and connect them to resources, be it tangible resources, or just counseling or insurance guidance, [and] do that before the hardship can occur. And the goals of our pilot phase are to (1) develop and refine a tool that's both predictive, but also feasible to administer within a busy clinic setting. And then also (2) to work with our interdisciplinary team to adapt the workflow. We can have a great tool, but if we don't have a way to administer it in a clinic, it's not going to do us any good. So for us, that means listening to feedback from, first and foremost, our patients and then the key stakeholders in the process. Our nurses have been integral to this process. We also, of course, our Patient Financial Services, staff, the clinical operations staff, obviously, IT, social work. And once we have these processes figured out and we have our tool solid, we will hopefully expand the screening to all services, and then use data to figure out the optimal screening interviews by disease and treatment type because we feel that this could vary by a patient's treatment trajectory. Dr. John Sweetenham: You note in your poster that additional multilevel interventions are needed to address the problem of financial toxicity at a systems level, and of course, what you have done here is a really great and important step in helping to identify those patients. But identifying those patients who are at particular risk is only beginning of addressing the issue. Could you elaborate a little bit more on other areas that you're exploring in terms of the interventions that you're using? Dr. Bridgette Thom: Sure. And this idea of multi-level interventions comes from my social work training, where there's an emphasis on viewing the individual as being part of a series of dynamic and interconnected relationships and systems: the social ecological theory. So if we think of concentric circles with the patient at the center, there are cascading relationships that are going to impact the course of their care. We radiate out to families and caregivers, a patient's workplace if they're employed, the hospital and the providers there, and then look to bigger systems where a patient lives, their town. If it's in an urban setting or a rural setting, the type of insurance that they have, if it comes from their employer, or if it's a different insurance system, their community and then of course, broader, social, societal, more macro issues. My point and that of many others who work in this space is that we have to consider the context. We can't just build and test interventions that focus on a patient because the patient isn't existing in a bubble. They're existing in relationships with their caregivers, their health care providers, their health care system. And all of that exists in, for lack of a better word, a broken system of structural inequality, systemic racism, and conflicting values about health care as a right. Patient-level interventions are indeed important, but we can't place the burden solely on the patient. And we, as researchers and clinicians in this space, really need solutions that are going to reach across systems. I think, like you said, this project demonstrates that and this is something that I hear from patients in other work that I'm doing. For example, I'm working on a digital intervention to help young adult cancer survivors to build their financial capability and build their understanding of the health care system and insurance systems and financing and all of that. As I co-develop this intervention with patients and survivors, I'm hearing, 'This is great. I'm glad I'm learning these things, but at the same time, my co-pays are unmanageable,' Or, 'I might have to skip my survivorship appointment because I can't afford to take off work that day.' I think we have to really think about, like I said, the context and the bigger picture of the scope of the problem and build and develop interventions that acknowledge that. Dr. John Sweetenham: Well, as you say, very complex, multi-level problem and many interventions needed. But congratulations and kudos to you and your colleagues for addressing one component of this. And we're really looking forward to seeing how this develops and progresses in the coming years. And I'd like to thank you, again, for sharing your insights with us today on the ASCO Daily News podcast and telling us a little bit more about this great work. Dr. Bridgette Thom: Thank you so much for having me. I want to just acknowledge all of the work of our team. It has really been a team effort. We're looking forward to our next steps. Dr. John Sweetenham: And thank you to our listeners for joining us today. You'll find links to the poster discussed today on the transcript of this episode. Finally, if you value the insights that you hear on the ASCO Daily News podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. You can hear more about the MSK Affordability Working Group's efforts on the podcast, Cancer Straight Talk from MSK.   Disclosures: Dr. John Sweetenham: Consulting or Advisory Role: EMA Wellness Dr. Bridgette Thom: Stock and Other Ownership Interests (Immediate Family Member): Caladrius Biosciences, Mediwound, Sierra Oncology, Lipocine, MEI Pharma, Oncternal Therapeutics, Avadel Pharmaceuticals, Chimerix, Avidity Biosciences, Sutro Biopharma, Adma Pharma, Concert Pharmaceuticals, Processa Pharmaceuticals, Curis           An, IMV, Arcus Biosciences, Iovance Biotherapeutics, Qiagen, Revance Therapeutics, DermTech, Zimmer BioMet, Axonics Modulation, Halozyme, Autolus, Pavmed Inc       , Mereo BioPharma, and AADi Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.    

Prostate Cancer Update
Oncology Today with Dr Neil Love: Key Presentations on Genitourinary Cancers from the 2022 ASCO Annual Meeting with Dr Sandy Srinivas

Prostate Cancer Update

Play Episode Listen Later Jul 28, 2022 46:10


Featuring a discussion on abstracts in genitourinary cancers presented at the 2022 ASCO annual meeting with Dr Sandy Srinivas, moderated by Dr Neil Love.

Cancer.Net Podcasts
2022 Research Round Up: Multiple Myeloma, Breast Cancer, and Cancer in Adults 60 and Over

Cancer.Net Podcasts

Play Episode Listen Later Jul 28, 2022 31:34


ASCO: You're listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests' statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In the Research Round Up series, ASCO experts and members of the Cancer.Net Editorial Board discuss the most exciting and practice-changing research in their field and explain what it means for people with cancer. In today's episode, our guests will discuss new research in multiple myeloma, breast cancer, and cancer in adults 60 and over that was presented at the 2022 ASCO Annual Meeting, held June 3-7. First, Dr. Sagar Lonial discusses a study on treatment for newly-diagnosed multiple myeloma in people under 65.   Dr. Lonial is a professor of Hematology and Medical Oncology at Winship Cancer Institute at Emory University, where he also serves as Department Chair. He is also the Cancer.Net Associate Editor for Myeloma. View Dr. Lonial's disclosures at Cancer.Net. Dr. Lonial: Hello, I'm Dr. Sagar Lonial from the Winship Cancer Institute of Emory University in Atlanta, Georgia. And today I'm going to discuss one of the Plenary abstracts at ASCO 2022, which was the DETERMINATION study, again, presented at the ASCO Annual Meeting. For the sake of disclosure, I just want to make sure I list that I was an investigator on this study. I also have consulting relationships with Takeda, Celgene, BMS, Janssen, and other companies that have agents in the context of multiple myeloma. So the reason I want to talk about this study today is I think it's a really important study that was designed over a decade ago to really ask the question, with a really powerful induction regimen that uses what we now call the RVd regimen, lenalidomide with bortezomib and dexamethasone, do you really still need to have high-dose therapy and autologous transplant as part of the treatment approach? And so the trial was a very simple randomized trial that everybody received RVd induction. And then there was a randomization between early transplant and then going on to consolidation and continuous lenalidomide maintenance versus no transplant going on to consolidation and lenalidomide maintenance. So both arms actually received continuous lenalidomide maintenance, which is really one of the important endpoints of this study overall. And the reason I say that is there was a smaller study done in France a few years previous to this where patients only received 1 to 2 years of lenalidomide maintenance. And in that trial, clearly the use of transplant was better. And the remission duration for the group that received the transplant was about 48 months. So the question was, with continuous lenalidomide maintenance, can you make that longer? So randomized trial, over 600 patients were randomized between these 2 arms. And the follow-up now is somewhere around 7 years in total. And what was demonstrated both in the ASCO Annual Meeting as well as in the paper that came out at the same time in the New England Journal of Medicine was that the remission duration was clearly longer in the group that had the transplant than the group that did not, even with both arms receiving continuous lenalidomide maintenance. And it was almost 66 months in the group that received the transplant, 21 months longer, almost 2 years longer than the group that did not receive the transplant. And so I think this is really important because what it says is that even in an era of really good induction therapy, transplant continues to offer significant benefit in terms of progression-free survival. Now, the reason progression-free survival is so important in this study is that we know that no time is more sensitive for treatment of myeloma than that first time we treat the patient. And so prolonging that first remission is really important because the disease is at its most sensitive at that time point. Now, there were questions about overall survival. Should we see an overall survival benefit? And I'll tell you, A, this trial was never designed to measure an overall survival benefit. And, B, the median survival for myeloma patients is now between 10 and 15 years on average. And so with only 7 year follow-up, it seems to me unrealistic to expect this to have a survival benefit at this early time point. So rather than saying there's no difference in overall survival, I think it's a fair statement to say at the short follow-up we have, there is no difference in survival. But I actually don't think survival is the right endpoint for newly diagnosed myeloma trials in fit patients because we do have so many important treatments to discuss. Now, there was also discussion about adverse events. Obviously, the quality of life during the transplant dropped a little bit. Not a big surprise. That lasted about 2 to 3 weeks, and then quickly, by 3 months out, returned back to baseline for almost every patient in the study. Additionally, there was a concern about second primary malignancies. If you look at this data, it's really no different than what we saw in the French study. There was a slightly higher risk of second primary malignancy, but we know that this is the case not only in myeloma, but in patients who receive alkylate-based therapy. And despite that, the progression-free survival was 2 years longer in the group that received the transplant than the group that did not. So I think, in summary, this is really an important trial because there are many groups that are making the case that perhaps we don't need transplant in this modern era of myeloma therapy. And I think that it's important to recognize that what we're looking at are not short-term endpoints. We're not looking at early MRD (minimal residual disease) negativity. What we're looking at is really ultimate measurement of clinical benefit, which to me is prolonging that first remission as long as you can. And so this trial clearly demonstrates that for young, fit patients, transplant continues to offer significant benefit, almost 2 years of benefit with continuous lenalidomide maintenance. And while there's a push to say perhaps we can think about which patients may or may not need a transplant, honestly, as clinicians, we're not good enough to make that prediction. And what I think is really important is that we not lose sight of trying to prolong that first remission with the best tools that we have. And I think even in this modern era of 2022, high-dose therapy and autologous transplant continues to be one of those tools, and we want to use it to maximize the duration of that first remission. So thank you again for listening to this brief summary of the DETERMINATION trial presented at the 2022 ASCO Annual Meeting and published in the New England Journal of Medicine. ASCO: Next, Dr. Norah Lynn Henry discusses new treatment advances for people with metastatic breast cancer, as well as 2 studies in early-stage breast cancer. Dr. Henry is an Associate Professor in the University of Michigan's Division of Hematology/Oncology in the Department of Internal Medicine and is the Breast Oncology Disease Lead at the Rogel Cancer Center. She is also the Cancer.Net Associate Editor for Breast Cancer. View Dr. Henry's disclosures at Cancer.Net. Dr. Henry: Hi. I'm Dr. Lynn Henry, a breast cancer oncologist from the University of Michigan Rogel Cancer Center. Welcome to this quick summary of updates in breast cancer from the 2022 ASCO Annual Meeting. I have no conflicts of interest for any of the trials that I will talk about. First, I'm going to give a very brief overview of the types of breast cancer, then talk about some research that was presented on both metastatic and early-stage breast cancer. As a reminder, there are multiple kinds of breast cancer. Some breast cancers are called hormone receptor-positive or estrogen receptor-positive and are stimulated to grow by the hormone estrogen. We typically treat those cancers first with antiestrogen treatments, which block estrogen or lower estrogen levels. Other breast cancers are called “HER2 positive.” These are often more aggressive cancers, but because they have extra copies of HER2, they often respond to treatments that block HER2. Finally, there are breast cancers that don't have hormone receptors or very much HER2. These are called triple-negative breast cancer and are also often aggressive cancers. One of the biggest stories from the ASCO Annual Meeting was the results of the DESTINY-Breast04 trial. In this trial, researchers studied a type of medication called trastuzumab deruxtecan, which is also called Enhertu. This drug is a combination of the anti-HER2 antibody, trastuzumab, plus a chemotherapy drug, and the antibody targets the drug to the cancer sort of like a guided missile. Trastuzumab deruxtecan is currently routinely used to treat patients with metastatic HER2-positive breast cancer. Now, the interesting thing is there was already data from studies that suggested that this drug might also work against breast cancers that have some HER2 receptors on the surface of their cells, but not so many that they meet the true definition of being HER2 positive. For the DESTINY-04 study, patients' tumors had to have either 1+ or 2+ HER2, which some people called “HER2 low,” and could be either estrogen receptor positive or negative. Two thirds of the patients were treated with trastuzumab deruxtecan, and the other one-third were treated with 1 of 4 different standard chemo regimens that their physician thought was the best treatment option for them. Treatment with trastuzumab deruxtecan was shown to lengthen the time people were able to remain on treatment. Importantly, it was also shown to increase the overall survival of patients compared to standard chemotherapy by more than 6 months for patients with estrogen receptor-positive cancer and by more than 10 months for patients with estrogen receptor-negative cancer. Since this is a drug that we currently use to treat patients with other types of cancer, we actually know a lot about its side effects. One key toxicity is it can cause a very severe inflammation of the lungs in a very small subset of patients. So this is something that we have to watch for very carefully. Otherwise, it is a relatively well-tolerated drug, especially compared to standard chemotherapy. The main side effects are nausea and fatigue. Another clinical trial presented at ASCO called TROPiCS-02 also studied a drug that is currently used to treat a different type of breast cancer. In this case, the drug is sacituzumab govitecan, also called Trodelvy. It is also a combination of an antibody that is targeted against cancer cells plus a chemotherapy drug. Sacituzumab govitecan is currently approved to treat metastatic triple-negative breast cancer. In the TROPiCS-02 trial, however, it was tested to see how effective it is for treating hormone receptor-positive, HER2-negative metastatic breast cancer. All of the patients enrolled in this trial had already been treated with antihormone therapy medications as well as at least 2 chemotherapy regimens. Half of the patients were randomized to treatment with sacituzumab govitecan, and the other half were treated with 1 of 4 standard chemotherapy drugs that their physician thought was the best for them. Those patients who were treated with sacituzumab govitecan had a longer time on average that the treatment worked compared to those who received standard chemo. They also had improved quality of life based on responses that the participants themselves provided on questionnaires. Although the overall benefit was rather modest, this drug may represent a new treatment option for patients with hormone receptor-positive, HER2-negative metastatic breast cancer, although at this time it isn't yet approved for treatment of this type of breast cancer. Both of these are examples of being able to take drugs that have been shown to treat 1 type of cancer and potentially expand it so that they can be used to benefit more patients with breast cancer. These drugs are also being tested to see if they are beneficial for treating early-stage breast cancer. So we await more hopefully very exciting results in the future. To switch gears a little bit, I'll now talk about another study I found interesting. This one is in the setting of early-stage breast cancer. So typically, radiation therapy is recommended after lumpectomy since it reduces the likelihood of cancer returning in the breast. However, questions have arisen about how much benefit radiation is actually providing for some patients whose risk of having cancer return in the breast is really low to start with. Therefore, these patients may be at risk of the side effects of radiation as well as other risks, such as financial problems, without actually getting much benefit from the treatment. Therefore, this trial, called LUMINA, evaluated whether radiation therapy was beneficial after lumpectomy for patients who have small, low-risk breast cancers and no lymph node involvement. The trial included 500 women who were at least 55 years of age with invasive ductal cancers that were no more than 2 centimeters in size. They had to be estrogen receptor-positive, HER2-negative, either grade 1 or 2, and Ki-67 low. Everyone had to be planning to take antihormone therapy for at least 5 years. During the 5-year follow-up period, a total of 10 patients out of 500, about 2.3% of all patients, had their cancer return in the breast. The researchers therefore concluded that for patients with this type of very low-risk breast cancer, it is reasonable to omit radiation therapy and just take endocrine therapy. Similar results have previously been shown for patients over the age of 70 with small lymph node-negative low-risk cancers, but this trial expands that option to patients who are as young as 55. Finally, I will touch briefly on the updated results from the ABCSG-18 clinical trial. So this trial enrolled postmenopausal women with early-stage estrogen receptor-positive breast cancer who are being treated with aromatase inhibitor therapy. Aromatase inhibitors are known to cause reductions in bone density. This trial therefore evaluated a medication called denosumab, also called Prolia, which is used to treat osteoporosis. Participants were randomized to treatment every 6 months with either denosumab or a placebo. They found that the patients who were treated with denosumab were half as likely to have a bone fracture. Importantly, patients treated with denosumab also had an improvement in bone density despite taking the aromatase inhibitor medicine, whereas those who received placebo had a decrease in their bone density over time. The other very interesting thing from this study is that patients who received treatment with denosumab were less likely to have their breast cancer return or to develop a new cancer during the 8-year follow-up period. So it's actually already recommended that postmenopausal patients with all types of early-stage breast cancer consider treatment with a different type of bone strengthening medicine called a bisphosphonate as part of their breast cancer treatment. The goal is to further reduce their risk of cancer returning. These new results will now lead experts to debate whether to also include denosumab as a potential additional breast cancer treatment option, not just to help protect people's bone density. There were a lot of other research findings presented that were related to treatment for both early-stage and metastatic breast cancer at the meeting. Importantly, we got glimpses of the many new drugs on the horizon for treatment of breast cancer, and we eagerly await the results of large, randomized trials so that the drugs that work can be used to care for patients with breast cancer. But for now, that's it for this quick summary of important research from the 2022 ASCO Annual Meeting. Stay tuned to Cancer.Net for future updates from upcoming breast cancer conferences. Thank you. ASCO: Thank you, Dr. Henry. Finally, Dr. Shakira Grant discusses 3 studies that looked at cancer in people 60 or older. This field is also known as geriatric oncology. Dr. Grant is an Assistant Professor in the Divisions of Hematology and Geriatric Medicine at the University of North Carolina at Chapel Hill and a board-certified Geriatric Hematologist/Oncologist. View Dr. Grant's disclosures at Cancer.Net. Dr. Grant: Hi, everyone. I am Dr. Shakira Grant. And I'm an assistant professor at the University of North Carolina at Chapel Hill. I'm also a clinician scientist with a focus on social disparities and how they influence the health and aging of older adults with cancer, primarily multiple myeloma. And for today's talk, I have no relevant conflicts of interest to disclose. It's such a pleasure to be able to talk today about the ASCO 2022 geriatric oncology and presenting key studies, which I believe were really practice-changing or really set up the foundation for informing future research directions. And to start us off, I wanted to start us with abstract 12012 by Dr. Mackenzie Fowler. And this was presented based on the University of Alabama at Birmingham's actual research group. And the title of their presentation was “Rural-Urban Disparities in Geriatric Assessment Impairments and Mortality Among Older Adults with Cancer.” And this was the result of a large registry study, predominantly patients with gastrointestinal cancer-- so cancers such as liver cancer, colon cancer. And what the authors really wanted to do here was to explore if whether or not living in a rural location, for example, is associated with having an impairment based on what people report in their ability to function at home, their quality of life. And they also wanted to see whether or not where you live, meaning a rural location, whether that can be associated with how long you are expected to live or your overall survival. So this was really a study that took patients who were truly older. There were patients who were above the age of 60. As I mentioned, these were patients predominantly with cancers of the liver, the colon, and the pancreas. And patients completed a baseline, what we call a geriatric assessment, to try to assess their overall or global health. And on these assessments, patients are asked questions about how they would rate their physical function and their quality of life. And what the authors found here is that in general, when patients lived in rural areas, this was associated with patients self-reporting more functional deficits, meaning that they reported that they had impairments in the ability to function at home from a physical perspective. They also had impairments in quality of life—so how you rate your general life and how you're doing from a day-to-day basis. And this was impaired if you lived in a rural residence. And then, importantly, this study also showed that living in a rural location—and, again, this study was centered in Alabama—that that was also associated with a reduced overall survival, meaning that people were found in rural areas to live a shorter life with these cancers compared to those who live in non-rural places or, as we call it, urban. And I think why I chose this particular study is because it's one of the first studies using a large data set of almost 1,000 patients that they have enrolled and really looking at the idea of the physical environment, so where a person lives, and how that really interacts with everything else to influence the health of an individual. And this study, I believe, really lays the foundation for an area of work in geriatric oncology where we are moving away from just thinking about the older adult, but we're also thinking about the older adult and the other identities. So we're really considering the sociocultural influence. So we think about race. We think about socioeconomic status, income. But now, we're also including the physical environment. And that is where people are living and spending the majority of their time. And that is in this study classified as rural-urban residency. So for this study, overall, I would say that this is really moving the field forward in a direction where we're moving away from just looking at just older adults, but we're thinking about older adults and all of the other stressors that they face, especially when they live in the community and how that impacts their health. The next study that I wanted to highlight was a study that was performed by Dr. Heidi Klepin at Atrium Health, Wake Forest Baptist. And this was a study that looked at evaluating the association between an electronic health record-embedded frailty measure and survival among patients with cancer. Again, this was an older adult population. It was just over 500 patients involved, and patients were over the age of 65. They had a new diagnosis of the most common cancers, which are lung cancer, colon cancer, and breast cancer. And the good thing about this particular study is that it sought to use data that is readily captured in the electronic health record to characterize a patient as fit, prefrail, and frail. So why is that important for the geriatric oncology community and even beyond is when we're dealing with older adults, we're always thinking about ways in which we can actually characterize their fitness and their ability to hence tolerate their therapies, being chemotherapy, and how likely they are to die if they're having these functional impairments. And so importantly, what this study showed was that in their sample, they found that up to 17% of people were characterized as frail using this index. And the significance of this finding is that when they looked at how long people were likely to live with these cancers, breaking it down according to if you were fit, prefrail, or frail, those who were frail had the shortest overall survival. So it means the time from which they were diagnosed until they die was much shorter than any of the other categories. And that equated to a difference between those who were fit and those who were prefrail of 10 months for those who were frail for overall survival and more than 54 months for those who were actually considered to be fit. So this is really, really important because what we are seeing is that if you are really fit, you are living on average with these cancers—the overall survival, at least for their institution, was more than 54 months. But then as you move across that spectrum of fitness, we're actually seeing that your survival decreases significantly. And so why is this important? So this is important because it's one of the first studies that is actually looking to operationalize the frailty measure for us to be able to potentially use and adapt into other health systems using data that we already collect. So it's no longer burdensome on patients to try to fill out additional forms or for other staff to be involved and collect this data. And this data is showing us that there is an association with this particular frailty index and the ability to predict overall survival-- so, again, a critical study in the geriatric oncology population looking at patients with the 3 most common types of cancer, which are lung cancer, colon cancer, and breast cancer, and really showing us that there is a way potentially to operationalize how we characterize the fitness level of an older adult and then using that data not just to say, "Yes, this person is frail," but for us in real-time to see results where we can see that there is a significant difference in terms of overall survival. Importantly, this is going to be a study where we continue to watch closely the developments over the next few years, especially as the authors and the research team note that their next steps involve looking at how to study how these frailty measures, or the frailty scores that people get when they come in and they're at baseline, how this changes throughout the course of treatment. And that has a lot of implications because now, we have the potential to start thinking about using a frailty-adapted approach to caring for older adults with cancer. What that means is when you're getting your treatment and we are following these scores, as we see things changing, this may be an indicator to us that, "Hey, we need to make some modifications in response to these frailty measures to make sure that our older adult population is able to tolerate their chemotherapies and have maximum benefit while also enjoying a good quality of life." So finally, I want to highlight this third study. And this was a study that was presented by Dr. Etienne Brain. And. Dr. Etienne Brain was also this year's B.J. Kennedy Award recipient. And each year ASCO recognizes the B.J. Kennedy Award recipient as an outstanding investigator who has made significant contributions in the area of research and clinical care of older adults with cancer. In this particular study, Dr. Etienne presented on behalf of his team the final results from a study that was looking at using endocrine therapy with or without chemotherapy for older adult women, so characterized as those who were over the age of 70, with a diagnosis of estrogen receptor-positive, HER2-negative breast cancer. And the importance for this study is that the question they sought to examine was whether or not patients who are in this age range still derive a benefit from receiving chemotherapy in addition to endocrine therapy. And what this study really showed is that there was no survival difference. Meaning when they looked at the data for 4 years, those who got chemotherapy plus endocrine therapy lived just as long as those who also just got endocrine therapy alone. And why this is important is because when you think about giving chemotherapy to an older adult population, as oncologists, we are always weighing the risks and the benefits associated with treatment. So we're always thinking about how tolerable is this drug likely to be? We want to minimize side effects because, at the end of the day, our goal is to treat the cancer, but we also want to focus in on the outcomes that matter most to the older adult population. And in general, these are things like maintaining your mobility, maintaining your mentation, maintaining good quality of life. And so we really want to make sure that we're balancing those risks. And this is why this particular study showing that with chemotherapy or without chemotherapy added to endocrine therapy, there seems to be no survival difference. This could be a way in which we move the field forward in thinking about a select group of patients with breast cancer and whether or not those patients truly need that extra toxicity or burden associated with using chemotherapy or whether endocrine therapy is enough. So with that, I will say across these 3 studies, even though they study different things-- we saw 1 study that looked at the intersectionality between older adults in terms of their chronological age but now starting to examine the influence of physical or social context and how that influences the health and outcomes for individuals with primarily gastrointestinal cancer. We also looked at the development of an electronic frailty index in patients with 3 most common solid tumors - lung cancer, colon, and breast cancer - and found that by using this frailty index collecting readily available data, that there was an association with predicting overall survival. And we saw that those who were characterized as frail had one of the shortest overall survivals. And then finally, in this study, looking at endocrine therapy alone versus chemotherapy and endocrine therapy, we saw that there was no survival difference again in an older adult population. And so what we are seeing here is a theme emerging as the importance of comprehensive evaluations of older adults and the importance also of these measures, when integrated across the research continuum, that they are useful in terms of predictive prognostic abilities and really lay the foundation for future research. So with that, I want to thank you for your time and thank you for listening. ASCO: Thank you, Dr. Grant. You can find more research from recent scientific meetings at www.cancer.net. Cancer.Net Podcasts feature trusted, timely, and compassionate information for people with cancer, survivors, and their families and loved ones. Subscribe wherever you listen to podcasts for expert information and tips on coping with cancer, recaps of the latest research advances, and thoughtful discussions on cancer care. And check out other ASCO Podcasts to hear the latest interviews and insights from thought leaders, innovators, experts, and pioneers in oncology. Cancer.Net is supported by Conquer Cancer, the ASCO Foundation, which funds lifesaving research for every type of cancer, helping people with cancer everywhere. To help fund Cancer.Net and programs like it, donate at CONQUER.ORG/Donate.

Oncology Today with Dr Neil Love
Key Presentations on Genitourinary Cancers from the 2022 ASCO Annual Meeting with Dr Sandy Srinivas

Oncology Today with Dr Neil Love

Play Episode Listen Later Jul 28, 2022 46:03


Dr Sandy Srinivas from Stanford University in California discusses key abstracts across genitourinary cancers presented at the 2022 ASCO annual meeting. CME information and select publications here (http://www.researchtopractice.com/OncologyTodayPostASCOGU22).

Cancer Stories: The Art of Oncology

"Good Genes," by Kaitlin Demarest: a resident searches for answers after genetic testing.   TRANSCRIPT Good Genes, by Kaitlin Demarest, MD1 (10.1200/JCO.22.00871) My mother was diagnosed with breast cancer when I was 5. I accompanied her to a handful of chemotherapy sessions and filled the time with MadLibs and word searches. The drive to the hospital became familiar; the diner where I celebrated my fifth birthday was on the way, as was the dairy bar and the Chi Chi's that shut down. I grew accustomed to her wearing wigs and remember vividly the time one almost flew off her head on a windy day at Rockefeller Center. I learned that vomit could be green and what a computed tomography (CT) scan was. This is not to say that I knew what was going on or what all of it meant. When she was first diagnosed, my dad explained that there was something scary growing inside my mom and her doctors needed to take it out. He drew an arrow coming out of a finger instead of breast tissue to help my young mind better grasp the concept. I was not sure why the cancer picked her breast to start growing in but that mattered little to me as my kindergarten logic figured it would be simple enough to take out. However, after “trying to get the cancer out” with surgery and chemo, she only seemed to get sicker. She would spend days on the couch after treatments, nauseous but not wanting the Coke syrup she would give me when I was sick. Eventually, she returned to work, her new head of hair much curlier than before, and things seemed normal again for a brief time. I can recall multiple times, almost yearly, that I believed she was cancer-free, but then I would overhear her telling someone over the phone that she needed to start treatment again. I clung to the belief that everything would be okay without a second thought, but then one day the summer after fourth grade, she told me and my brother that she would not be getting better. Soon she was in hospice care, and then she was gone. Losing her at 10 years old, there was so much I did not understand. I decided I wanted to become a doctor and tried to start my medical education as soon as possible to fill in these gaps. I wrote research papers on cancer topics in middle school, took as many science classes as possible in high school, and majored in molecular biology as an undergrad. I even spent a summer shadowing oncologists, including one of my mom's. He called me by her name a few times, which mostly warmed my heart that he still thought of her and reminded me that he had known her too. He was very kind, clearly doing the best for his patients. Watching him, I began to appreciate the rocky road of disclosing setbacks and poor prognoses as a provider. Despite a week of shadowing my mother's oncologist and countless visits with my aunt and uncle, both doctors, who had helped her navigate the treatment process and even took care of her when she was home on hospice, I refrained from asking about the genetics of my mother's cancer. Perhaps due to wishful thinking, I was under the impression that my mom had been tested for hereditary breast cancer syndromes while she was alive and that she was negative for BRCA mutations. But finally, at the end of my first year of medical school, over the karaoke music at a bar after my cousin's college graduation, my aunt told me that she had never been tested; I would need to be tested soon. I had been scared to receive the results of my genetic testing. I had faced mortality but avoided thinking about my own. I remember my heart pounding as I listened to my genetic counselor, trying to discern any doom or gloom in her tone. After she carefully explained that I carried no mutations known to be associated with cancer, I caught my breath and relief did wash over me. Then it was all over. Years of questioning, asking what if, bargaining, avoiding, wondering, hoping all tied up. “Take care of yourself, Kaitlin,” she said, “Don't study too hard tonight.” It was almost as if she knew. The sudden silence, the finality, and the lack of solace in my solitude; I felt panicked and empty. There would be no sticky little mutation to act as scapegoat for all my pain, no genetic alteration on which to pin her loss. I would not have to think so much about prophylactic mastectomies, only early screening. But I was devastated. I thought knowledge would mean power, but it turned out that ignorance was almost bliss. I secretly hoped for an answer, written in our DNA, a molecule I had come to understand so well, that would explain why I had lost my mom so prematurely. As a kid, I felt helpless against my mother's illness and these results only exacerbated that feeling. Studying molecular biology and human physiology granted me some sense of control, but my heart ached not knowing what happened inside of her organs, tissues, and cells. I knew a lot about cancer but virtually nothing about hers. I could not let cancer have any secrets. There are a lot of things I know and remember about her. Her love of grocery store–related game shows. Her frustration over untangling my hair each morning before school. Her Armenian way of dancing; her arms twirling along to Santana on the radio at a traffic stop. But it made me feel so far away from her to learn about the histology, diagnostic workup, and treatment of breast cancer and not know anything about her experience. Our time was cut short, so many stories left untold. Any morsel of information I could remember of her was proof of our time together and that our relationship was special, despite how young we both were when we were separated by her death. If I could not ask her about her hobbies growing up, her social life in college, or what it was like being pregnant with me, I was going to learn about what made that impossible. I remember hearing that my aunt and uncle still had her medical records and, after asking them, they arrived in the mail along with old Mother's Day cards and letters to Santa. The woman kept everything. It took me a few nights, locked in my room, chasing the grief with episodes of The Marvelous Mrs. Maisel, but I made it through every page. She had a modified radical mastectomy and a transverse rectus abdominus muscle flap reconstruction, an echocardiogram prior to doxorubicin, and required Neupogen to keep her white count up. Other things I had already known: menarche was at age 11 years, she wore a sleeve to improve the lymphedema in her left arm after her lymph node dissection, she had two c-sections, and she smoked cigarettes for a brief period. Also documented was my parents' divorce and the fact that they had me and my brother, our ages swapped. Everyone always thinks he is the older one. It was satisfying and heartbreaking. Now I knew the type of cancer and its stage and size at diagnosis. I knew that she had surgery followed by many cycles of chemotherapy then radiation and tamoxifen. After all of this, according to an office note, she was “basically doing extremely well.” But I read on and on as her tumor markers kept rising. 52. 94. 178. 145. 375. Scan after scan showed no evidence of metastatic disease, until they finally did. One year, three CT scans, three bone scans, and a positron emission tomography CT later, she was found to have bilateral pleural effusions, liver metastases, and omental caking. She had been on estrogen deprivation therapy with Zoladex which was not working, so it was decided to perform a laparoscopic oophorectomy. The oophorectomy converted to an open procedure due to adhesions, bilateral Krukenberg tumors, and extensive carcinomatosis. Mostly lab sheets remained after that, with platelet counts and international normalized ratio checks after she was placed on warfarin for a blood clot. The very last page was a list of information requested by the cancer center at which she was to start another round of chemotherapy to control her progressive disease. On it, she wrote a note to remind herself to have the office reach out to my physician aunt with questions. Even at this stage, she had hope chemotherapy would prolong her life. As painful as it was, I got my answers, which showed me just how powerful and therapeutic it can be to feel informed. I had harbored so much grief for so long because not understanding my mother's cancer made her feel that much farther away. Many would expect the relief but not the heartbreak from hearing my negative results. The truth is, good news is good but it is also new. It does not erase the pain, worry, and loss that may have preceded it, and it does not necessarily indicate a clear path forward. New information can anchor us, quench our anxieties, or it can be an unpleasant surprise. My experience has taught me that you cannot predict how news will land on the ears and hearts of someone else. This makes it so important to leave one's own expectations behind and to give patients the time and space that they need to process. As healthcare providers, we always want to be the bearers of good news, but we must remember that every patient has an undocumented history and any conversation can be a delicate one. As I write, my internal medicine residency training quickly approaches. I am still shaking down cancer's secrets but feeling closer to my mother than before. As a physician, I will meet patients and their families on some of the scariest days of their lives. I cannot take away all of their fear, but I can walk with them through all of the knowing and not knowing and make space for relief and grief alike. I hope I will always remember that my every day could be the longtime culmination of loss, worry, and anticipation for someone else. I am grateful for the good genes, good memories, and good purpose in life my mom gave me, and I will do my best to make her proud. Dr: Lidia Schapira: Welcome to JCOs Cancer Stories: The Art of Oncology, brought to you by ASCO podcasts, which offer a range of educational and scientific content and enriching insight into the world of cancer care. You can find all of the shows, including this one at podcast.asco.org. I'm your host, Lidia Schapira, Associate Editor for Art of Oncology and Professor of Medicine at Stanford. And with me today is Dr. Kaitlin Demarest resident at the University of Pennsylvania. We'll be discussing her Art of Oncology article, 'Good Genes'. Our guest has no disclosures. Kaitlin, welcome to our podcast. Dr. Kaitlin Demarest: Thank you so much for having me. Dr: Lidia Schapira: It is a pleasure. I just like to start the conversation by asking authors to tell us what they're currently reading or what they recently enjoyed and would recommend to a colleague, what could I find on your night table? Dr: Kaitlin Demarest: I recently finished a book called Middlesex. It's not a very recent book, but it's actually one of the books that I remember my mom reading when I was a kid, and I've wanted to read it since then. It's incredibly beautifully written and it has a medical thread through it as well, I would absolutely recommend it. Definitely one of my favorites. Dr: Lidia Schapira: I really enjoyed that book. It's one of my favorites, too. So, you're currently a medical resident, correct? At Penn? Dr: Kaitlin Demarest: Yes, this is my second week. Dr: Lidia Schapira: And how's it going? Dr: Kaitlin Demarest: It's been so great. I started in the outpatient setting. So it's been nice to step into that PCP role. Dr: Lidia Schapira: Fantastic! Well, maybe we can even interest you in pursuing a career in cancer medicine. Dr: Kaitlin Demarest: Absolutely. Dr: Lidia Schapira: But let's turn to your essay, 'Good Genes'. You share with us that your mom was diagnosed with breast cancer when you were 5, and that you lost your mom when you were 10. Tell us a little bit about what motivated you to write the essay and then send it to us at JCO. Dr: Kaitlin Demarest: Sure! It actually was when I was writing my personal statement for residency applications. My mom's experience with cancer is very much linked to why I want to be a doctor. And so, I think that's why it came up when I was writing that personal statement. I think I just had a lot to put down on paper after I'd gone through her medical records. And it was really therapeutic actually, to write it all down. And a friend encouraged me to send it in. Dr: Lidia Schapira: There's an interesting comment there and one that I want to unpack a little bit. Writing to process an important emotional experience is therapeutic, but then the decision to share it, and in this case, perhaps share it with your future colleagues and attendings in medicine, requires sort of an additional step. What made you want to share the story with a broader community of cancer clinicians? Dr: Kaitlin Demarest: I think I was really comforted by my genetic counselor who probably hasn't read something like this, but she just seemed to be so in tune with the range of responses that someone can have when they get genetic testing results. And I wasn't even expecting the reaction that I had and I thought that maybe it could be helpful both to people who undergo genetic testing, but also to any provider who's delivering those results. Dr: Lidia Schapira: So, let's talk a little bit about the theme of your essay, sharing important medical news, in this particular case, the results of a genetic test. Tell our listeners a little bit about what made you want to be tested? And then how did you receive the news of the genetic test? Dr: Kaitlin Demarest: I knew I was going to need to be tested for a while because my mom was so young when she was diagnosed. So, it was indicated for me. And I understand how it can be a daunting decision for a lot of people. But I hold fast to the notion that knowledge is power. I'm very grateful that I underwent the testing and it really set me up with a great plan to get screening done very regularly. It's sort of a setup for that process. It honestly has brought me a lot of resolve knowing that I'm doing what I need to do in order to best protect myself for the future. Dr: Lidia Schapira: I'm very happy to know that you feel this resolve and you feel good about it. But you write in the essay and share with us that initially, it was devastating to hear that you did not have an inherited susceptibility that we could name. My interpretation of that statement and I want you to react to that was that in a way it made your mother's cancer more mysterious, not knowing the cause, not knowing what the danger was made the threat of the potential genetic susceptibility more vague and diffuse. Tell us a little bit about what it was for you. Dr: Kaitlin Demarest: Exactly. When I found out that I didn't inherit susceptibility, it did make it seem a bit mysterious, both for my mom and for myself. She didn't have genetic testing done, which makes it a little bit more confusing as well. But I think I was really hoping for an answer to explain why she was diagnosed so young, although that would have been difficult news to receive as well knowing that I had inherited something that could lead to cancer. Dr: Lidia Schapira: I found your insights incredibly powerful about the idea that news is just news, and the lens through which somebody receives the news may be different from that of the person who's sharing the news. You make this reflection that you hope that as a physician, you will sort of listen to what's happening with your patients. Tell us a little bit about this idea that even good news that you had good genes wasn't necessarily experienced by you in the moment as good? Dr: Kaitlin Demarest: Definitely news is new and it takes time to process that, even if it's expected to be good. And like you said before, I feel like it is good news now, but when I originally heard that information, I really needed to process what that meant, for me, but also, it just made me realize that there was more processing of my mom's death that I needed to do. Every time we deliver news to a patient, we have no idea what brought them to that space and what is going to come up when they receive that information. Dr: Lidia Schapira: I admire the genetic counselors. Their training is specific to their discipline, but they're also trained in communication skills. I think that is so incredible because, as you say, they can't anticipate how the news is going to land. They have that moment, that sort of teachable moment, to help people begin to process what they've just heard. So, let's talk a little bit about the other piece of the essay, which is that you sought to connect to your mother or you needed to understand the details of your mom's history. And so, you found her records when you were in medical school and sort of able to read through them. I have this image of you locking yourself up in your room instead of listening to Fabulous Mrs. Maisel and even getting some snacks and just pouring your heart and soul into reading this. Can you tell us a little bit about that experience? Dr: Kaitlin Demarest: I think, I would have loved to have processed this a lot sooner, but I think going through the medical records in medical school was a good time to do it because I had a better understanding of what I was reading. It took me probably three nights. I don't think they were three consecutive nights because it was definitely heavy. It was really difficult to read how things progressed and to understand the weight of it all. And not only to read what was happening in her records but to think back and remember those times and being able to look back at those memories with new knowledge filled in a lot of gaps for me, but it was definitely difficult. I feel like I have more to say but I'm struggling to find the words. Dr: Lidia Schapira: Reading your essay, I have the impression that there were many adults who tried to help you as you were developing your own ideas about what had happened to your mom - your aunt, your uncle, your mom's oncologist who allowed you to shadow him in the clinic, which I found very endearing. Can you tell us a little bit about what was helpful, and which ones of these experiences actually were helpful to you? Dr: Kaitlin Demarest: I remember when I received the results, and I was very upset. I called my dad and my stepmom. I think it was my dad who told me that my aunt would probably have her medical records. She sent them right away. Just knowing that my aunt and uncle who are both physicians helped her so much through this process has been incredibly helpful and just very touching. They've been so helpful to me and inspiring to me as I move forward through my medical career. They are the ones who helped me set up a time to shadow my mom's oncologist. And he taught me a lot about breaking news to patients. It was really amazing to get to work with him because I could see how much he cared for his patients and knowing that he was one of the people caring for my mom felt really good. Everyone in my family has been so encouraging of me since I said I wanted to be a doctor when I was 8 years old and they've never made me feel pressured to pursue anything in particular, but they never made me second guess this purpose. Dr: Lidia Schapira: As oncologists, we often tell our patients who are not going to be able to see their kids grow up that their kids are going to be alright and I hope your mom had that feeling that you were going to be alright. Listening to you now I can only imagine how proud she would be of the doctor that you've become and planned to be. What message would you like the readers of your essay and listeners of this podcast to take away from the story? Dr: Kaitlin Demarest: I hope that readers will not shy away from daunting news, whether that means they're the ones hoping to pursue testing or screening, or whether they are providers who are nervous about these kinds of conversations because while they can be very uncomfortable and they can be emotional, they're so, so worth having because they can really protect the health of a lot of people and it's a really great opportunity to form a very trusting relationship that can have a really positive impact for the long term. Dr: Lidia Schapira: And it gives meaning to our work as well. Dr: Kaitlin Demarest: Of course. Dr: Lidia Schapira: It's one of the reasons that many of us get up and go to the clinic every day or every week. It's been lovely to hear your story, Kaitlin. You're a terrific writer. Your insights are very powerful. I thank you for sharing your story with us and I sincerely hope that you consider a career in medical oncology. Dr: Kaitlin Demarest: I'm very much considering it. Thank you so much for having me. Dr: Lidia Schapira: Until next time, thank you for listening to this JCOs Cancer Stories: The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple podcasts or wherever you listen. While you're there, Be sure to subscribe so you never miss an episode of JCOs Cancer Stories: The Art of Oncology podcast. This is just one of many of ASCO's podcasts, you can find all of the shows at podcast.asco.org.   The purpose of this podcast is to educate and inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.    

Erre que ELE: Para hablar español
118. La actualidad política y social da asco: ETA y el franquismo | Español intermedio y avanzado

Erre que ELE: Para hablar español

Play Episode Listen Later Jul 25, 2022 43:11


En este episodio te hablo de lo frustrante que llega a ser la política en España, intentando siempre dividir a los ciudadanos y mentirles, solo para desviar la atención y ganar votos. En este caso, te explico una situación que ha ocurrido hace unos días y que trata sobre la Ley de Memoria Democrática, el franquismo y ETA. Aunque esta vergonzosa situación ha sucedido hace muy poco, se trata de algo que siempre está presente. Para que puedas entenderlo bien, te hablo también del contexto histórico y de algunos datos concretos: ¿Qué era ETA? ¿Qué hizo? ¿Sigue existiendo? ¿Qué pasó con Miguel Ángel Blanco? ¿Qué relación hay entre las víctimas de ETA y las víctimas del franquismo? ¿Qué pasa con las víctimas del franquismo ahora? ¿Cómo utilizan los políticos estos asuntos cuando les interesa? Tienes el artículo de este episodio (con explicaciones y curiosidades) y ejercicios para practicar su vocabulario en: https://academia.errequeele.com/ Aprende ESPAÑOL REAL gratis con las anécdotas, historias o actividades de mis correos: https://academia.errequeele.com/suscribete-a-erre-que-ele/

The ASCO Post Podcast
ASCO 2022: Conversations in Gynecologic Oncology

The ASCO Post Podcast

Play Episode Listen Later Jul 22, 2022 18:28


In this episode, we're featuring two conversations focusing on gynecologic oncology, both led by Dr. Ursula Matulonis, of Dana-Farber Cancer Institute. Dr. Matulonis, along with two colleagues, reviews data presented at the 2022 ASCO Annual Meeting in ovarian, primary peritoneal, and fallopian tube cancer.To listen to more podcasts from ASCO, visit asco.org/podcasts.

Cancer.Net Podcasts
Reflecting on COVID-19 and Providing Reliable Information to People with Cancer, with Merry Jennifer Markham, MD, FACP, FASCO

Cancer.Net Podcasts

Play Episode Listen Later Jul 21, 2022 17:50


ASCO: You're listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests' statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses.  The beginning of the COVID-19 pandemic brought with it confusion, fear, and uncertainty for most people around the globe. These feelings were often heightened for people with cancer as they experienced disruptions or changes in care, such as following greater safety precautions at their treatment centers, having their appointments shifted to televisits, and facing delays in recommended cancer screenings.  As a response to the COVID-19 pandemic, Cancer.Net developed several resources for people with cancer, including its post “Coronavirus and COVID-19: What People With Cancer Need to Know,” written by Dr. Merry Jennifer Markham. After publishing this post on March 3, 2020, Dr. Markham reviewed and updated the post for 650 days straight to make sure people with cancer were receiving the most up-to-date and relevant information about COVID-19. The post went on to receive the Award of Distinction from the eHealthcare Awards in the Best COVID-19 Pandemic Related Communications category and was translated into Spanish, Portuguese, Russian, and Arabic.     In this podcast, ASCO's Chief Medical Officer, Dr. Julie Gralow talks with Dr. Markham about her role in creating information for people with cancer throughout the pandemic, how the pandemic has shifted her perspective, and where she sees the future of the pandemic response headed. Dr. Gralow: Hello. I'm Dr. Julie Gralow, ASCO's Chief Medical Officer. Today, I'm talking with Dr. Merry Jennifer Markham, an ASCO volunteer and the Cancer.Net Associate Editor for Gynecologic Cancers. Cancer.Net is the patient information website of ASCO. Dr. Markham is also chief of the University of Florida, Division of Hematology and Oncology, a clinical professor in the University of Florida College of Medicine, and the associate director for medical affairs at the University of Florida Health Cancer Center. Dr. Markham played a key role in ensuring that ASCO provides up-to-date information about COVID-19 for patients, survivors, and caregivers through Cancer.Net. Since March 2020, she devoted a remarkable amount of time and energy to this endeavor, including a stretch of 650 straight days of reviewing and updating our patient information about coronavirus. Wow. That's true dedication, Merry Jennifer. So I would like to kick it off to you, Merry Jennifer. First of all, thank you so much for everything you've done during these past couple of years in keeping our Cancer.Net website up to date for patients during these incredibly challenging times. I'm looking forward to having a conversation with you about all of this. Dr. Markham: Thank you so much. It's been an honor and a pleasure. And the Cancer.Net team has been just fantastic to work with. Dr. Gralow: Great. Glad to hear it. So Merry Jennifer, when you suggested that ASCO provide some patient-focused content on COVID and cancer, did you think we'd still be talking about this 2 years later? Dr. Markham: Oh, I had no idea what to expect. No. I think I, like many of us, thought that this would be a very time-limited event and maybe by the Christmas time of 2020, that we would be done. We were all, of course, disappointed to learn that that was not how a pandemic plays out, but I definitely had no idea what my one email to the group would lead to. Dr. Gralow: What do you remember about March of 2020? Dr. Markham: It was a really scary time and a very uncertain time. None of us really knew what was going to come. We were watching how the pandemic or just the viral infection was playing out at the time in other countries, but really, we're not sure what was going to happen to our patients. And I was coming off a stint, I believe - the timing is a bit of a blur - on the communications committee for ASCO. And communications is something that I am passionate about, cancer communication with patients and with other colleagues. And I recall being in clinic and answering questions from patients. And really, it felt like there needed to be some broader level of communication that our patients could refer to you but also colleagues and people around the world. That's what I remember. And I remember reaching out and saying, "Hey, I wonder if maybe ASCO should do something." I didn't intend to volunteer myself to do something, but somebody needed to jump in, and I was ready. Dr. Gralow: Well, I was still practicing at the time, and I know all the different questions that we were getting. It was such a confusing time. We didn't have information. It was changing on a daily basis. I'm impressed that you thought that we were going to be dealing with this maybe even until the end of 2020 because I was thinking, "Oh, 3 or 4 weeks. We can all quarantine for 3 or 4 weeks. Right?" And here we are more than 2 years later. So you worked on the content for 650 days straight. I mean, every single day for 650 days, you looked to make sure that what we had on there was accurate, and now we backed off a little. But you're still looking at the content a couple of times a week. How has that level of focus on COVID-19 affected your perception and experience of the pandemic? Dr. Markham In the very beginning, the content was really updated daily. I think something was changing on a daily basis. And so it became part of my morning habit, first thing in the morning with a cup of coffee if I had time for that, to read whatever was happening in the news that day and just paying attention to where we were headed, knowing that there would be changes. In the beginning, there was not enough masks, so we weren't recommending everyone “Go out and buy surgical masks." And then the policies changed on that as we had plenty of masks and then, of course, vaccines and so on and so forth. I think I felt, like many people, a loss of control when the pandemic happened. Right? I think that so many people felt the sense of loss and the sense of uncertainty. And it reminded me actually of what patients with cancer probably experience with a new diagnosis, the sense of loss and uncertainty for what the future holds. And I think like many of my patients who really want to dive in deep to the research of their own cancer and treatment course, it actually gave me a sense of comfort to delve deep into the facts of what we were learning on a daily basis about COVID. Having that knowledge at my fingertips and being able to put it into layman's terms really did help me, I think, not become emotionally tied up in all of the sadness of the pandemic and the loss of travel and the loss of being able to be with loved ones. So for me, it was a little bit of a coping mechanism, I think. I didn't realize that at the time, but in hindsight, I really think it was. Dr. Gralow: So becoming a true expert in COVID and cancer was your coping mechanism. That's interesting because you were the leading authority here on what everyone was recommending. Do you have any particular moments, good or bad, that really stand out for you from those early days? Dr. Markham: I think what stands out the most is we focus so much on science as practitioners of oncology and in these health professions and as scientists. And I remember being very disappointed and hurt whenever I encountered someone, whether it was a patient or a family member or a colleague or-- not colleague but acquaintance, perhaps, who didn't believe that this was a real thing. And I was really pouring my heart and soul into the work of providing patient education on this and trying to do the same in my own clinic and with my own family members. And to have people brush it off as a non-thing, it was hurtful, and it was also just very disappointing as a physician and scientist. Dr. Gralow: And things were changing fast. Now, you yourself ended up with a COVID diagnosis at the end of 2021. Did that personal experience change the way you viewed ASCO's roles in supporting people with cancer throughout the pandemic? Dr. Markham: So I was minimally symptomatic, which was really thanks to science and thanks to the vaccines and having boosters. So number 1, it was very mild. But like many people who have a diagnosis that's new to them, I was nervous. And so I did feel reassured, though, because I had a pretty good understanding of what was happening and what was going to happen, and I knew that I was protected because of the vaccine and boosters. But it can be a scary time, and I think that it just gave me a little more insight into what people who I've taken care of, who have cancer and then have experienced a COVID diagnosis, have felt. Unlike my patients with cancer, I'm not immunocompromised, so I felt pretty comfortable. But it can certainly be scary. And I did have that appreciation for-- not just the infection but having to isolate myself from my family, I think that really was the hardest part and the inconvenience of it. Dr. Gralow: Well, I'm glad you just had a mild case, and hopefully, you have no residual symptoms. But it is interesting when you have, either within your family or yourself, a personal confrontation, either with COVID or with cancer, that it gives you a different perspective. Dr. Markham: Absolutely. That is so true. Dr. Gralow: So we're now 2-plus years into the pandemic. I know you don't have a crystal ball, and I know we've thought we were on the downswing and things picked up again. But where do you see this going? I mean, not just COVID itself but public health, immunizations, the whole pandemic awareness. Where do you see this going in the U.S. and worldwide? We've had the flu coming around every season. We didn't wear masks. We have vaccines. Not everybody got vaccines. What are we going to learn from all of this, and where do you see the future will be? Dr. Markham: I think that one of the major learning experiences that all of us who are in medicine and health care and those in health communication and health policy-- what we have learned is that science communication really does matter, and it's hard to do it in a very rapid-fire pace and do it well. But I think we've all seen examples of how communication around factual data and removing misinformation is actually critical. I would love to see this pandemic go away, but I think that what we've seen over the last couple of years with the new variants coming out, it's clear that we're not going to have 99% of our population vaccinated. I think, really, on all fronts, vaccination uptake is not that high. So there will be people who are either unable or unwilling or who will defer getting vaccinated. And unfortunately, this will lead to these waves of new variants coming like the current variant that is circulating. But I do think that there is hope. One of the reasons that a lot of my patients delayed getting vaccines in the beginning-- many of mine did, but there were some holdouts who really were not comfortable getting vaccinated. There is now more time. And so we do have more safety data, and we know that the vaccinations are safe against-- the COVID vaccinations are safe. So I think that I have seen more patients in those last 6 months become vaccinated. They were holdouts initially, and now more are doing it. And I'm hopeful that this trend will continue. I do think there are pockets where we are seeing vaccination rates start to pick up again. I don't know. I'm happy to keep reviewing content, though, and updating. The updates have become a little less frequent, which is great. I love when our focus on updating is really on new therapies and new vaccines and new vaccine sequences and schedules. So I think we're in a fairly stable place - knock on wood - right now. Dr. Gralow: In our immunocompromised population, which is only a subset of all of our patients with cancer, do you think we'll see more mask wearing in the future? Dr. Markham: I do. I do think that actually this is one area where we, as a culture, have probably begun to shift in the United States and especially among people who have a personal risk or a family member with a risk factor that might increase their chances of severe COVID. Just a personal anecdote. I traveled internationally for the first time since COVID a couple of weeks ago, and my entire family, all vaccinated and boosted, wore our masks, as it's the federal requirement to do so on planes. However, we landed in an international location where that was not a requirement. None of us wanted to take our masks off. We felt more comfortable, and I saw a lot of people who also remained masked even though it was not a requirement. So I do think there's a shift in this culture. I'm as tired of the masks as anyone, but it really does have a protective measure and is, I think, important, especially for our patients who have a weakened immune system or other medical risk factors for developing COVID or other infectious diseases. Dr. Gralow: So kind of in closing, you did such tremendous work for ASCO, for our patients with these regular updates. But what's the experience meant to you as an ASCO member and a member of the oncology community? Dr. Markham: I joined ASCO when I was a fellow, and I was taught the importance of our organization by my faculty members and my mentors. And as soon as I realized I could, I volunteered to serve on ASCO committees and task forces. And it has been one of the most rewarding parts of my career. And it's something that I encourage junior faculty and fellows to do as well. ASCO is such a leading voice. It is the leading voice for oncology care globally. And just the opportunity to contribute something back has really meant the world to me. It's been an honor to be able to do this work. Dr. Gralow: Well, on behalf of ASCO, I want to thank you again for all of your commitment to this. We're thrilled to have you as a volunteer, and we will continue to call on you as a volunteer. Really appreciate that. And I do know that throughout the COVID-19 pandemic, a lot of what ASCO was posting, a lot of the webinars we had, etc., were being used around the world. And you contributed majorly to that as well. So for that, I thank you. And I thank all of our listeners. This has been Julie Gralow and Merry Jennifer Markham talking about our Cancer.Net COVID-19 information that Merry Jennifer tirelessly led daily, essentially, for a couple of years. So thank you so much for that. It's been great talking to you. Dr. Markham: Thank you. ASCO: Thank you, Dr. Gralow and Dr. Markham. Find all of Cancer.Net's resources on COVID-19 and cancer at www.cancer.net/covid19. Cancer.Net Podcasts feature trusted, timely, and compassionate information for people with cancer, survivors, and their families and loved ones. Subscribe wherever you listen to podcasts for expert information and tips on coping with cancer, recaps of the latest research advances, and thoughtful discussions on cancer care.   And check out other ASCO Podcasts to hear the latest interviews and insights from thought leaders, innovators, experts, and pioneers in oncology.  Cancer.Net is supported by Conquer Cancer, the ASCO Foundation, which funds lifesaving research for every type of cancer, helping people with cancer everywhere. To help fund Cancer.Net and programs like it, donate at CONQUER.ORG/Donate. 

ASCO eLearning Weekly Podcasts
Oncology, Etc. - Finding Your Voice: A Tale of Healing and Rediscovery

ASCO eLearning Weekly Podcasts

Play Episode Listen Later Jul 19, 2022 48:34


Drs. David Johnson (University of Texas) and Patrick Loehrer (Indiana University) host this live ASCO podcast with award-winning documentary producer/director Bill Brummel. After undergoing a laryngectomy in 2016, Mr. Brummel produced and directed a documentary film titled “Can You Hear My Voice?” that chronicles the one-of-a-kind Shout at Cancer choir, whose members have all had their voice boxes removed, as they prepare for the most ambitious concert. This podcast features audio clips from the film. Mr. Brummel, who is joined by his surgeon, Dr. Uttam Sinha, of Keck Medicine of USC, reflects on his own cancer experience and the psychosocial impact of losing one's natural voice. For more information about the film or hosting a screening, visit www.canyouhearmyvoice.com or email info@bbprods.com. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org.   TRANSCRIPT Dr. Dave Johnson: So we're back here with another episode of our world-famous Oncology, Etc. podcast with two very distinguished guests, Pat.  Dr. Pat Loehrer: Well, we're thrilled to be here to record this episode in front of an audience. Usually it's just Dave and I, and supposed to be a live audience. Although after three-and-a-half days of ASCO, I'm not sure if anybody's still alive. We have two very distinguished guests today. Mr. Bill Brummel is the award-winning documentary producer and director. He and his films have been recognized with the Peabody Award, two International Documentary Association Awards, five national Emmy nominations, and have been named for the Oscar shortlist. Many of Dr. Brummel's films have focused on civil rights and human rights issues.  After having his voice box removed in 2016 due to complications from radiation therapy, which he received for his head and neck cancer, Bill produced and directed Can You Hear My Voice? This film, which has not yet been publicly released, was shown on Saturday afternoon here, chronicles London's Shout at Cancer Choir, whose singers are living without voice boxes. It's amazing. The ASCO Annual Meeting attendees saw this on Saturday, and today what we're going to do is hear and see some of the clips from the movie and hear from the director himself.  Dr. Dave Johnson: We're also joined by Bill's physician Dr. Uttam Sinha who encouraged Bill to create this documentary about the psychosocial aspects of living without a voice box. Dr. Sinha is an Associate Professor of Otolaryngology at the University of Southern California where he tells us he spent the bulk of his life. He's also the Watt Family Endowed Chair for Head and Neck Cancer at his institution. Dr. Sinha's holistic medical approach was really truly critical, Bill tells us, to his both physical and emotional recovery following laryngectomy. So Bill, Dr.Uttam, welcome to Oncology, Etc.  Mr. Bill Brummel: Thank you very much. But one thing your audience should know and you should know is that after having a laryngectomy, speaking with a voice prosthesis, we lose the ability to laugh out loud. So, Pat and Dave, if you happen to tell a joke or say anything funny, know that I'm laughing inside.  Dr. Pat Loehrer: I think Dave and I think that most of the people that listen to our podcasts probably have had laryngectomies because we hear no laughter at all from anything we say. So, Bill, we're really here today to talk about your documentary. And we're going to show a few clips. But before we show the first clip, can you set this up for us?  Mr. Bill Brummel: This clip sets up the choir and the premise of the film. We follow the choir as they prepare for the most ambitious concert they have ever attempted. So it's really just setting up the premise.  Dr. Pat Loehrer: Now this is extraordinary. So if you could run the first clip for us. Appreciate it.  [Clip starts playing]  Speaker 1: I'll remember quite well, when I first suggested let's form a choir. They responded with laughter and surprise and disbelief.  Speaker 2: It just seemed ridiculous that you would expect a group of  people with no voice boxes to stand up and sing in a choir. It didn't seem realistic. But Thomas had confidence that we could do some things. We went along with his mad scheme. And then one day was sort of now, what about a concert? What?  [Jazz playing]  Speaker 3: Well, the people in the choir are just normal people.  Speaker 4: I really admire the courage that it's kind of taken to come through all of their treatment.  Speaker 5: After all the stuff they'd gone through, they're able to turn that into something creative and artistic. That's really, really impressive.  Speaker 2: The concept is something new. It's almost a defiance, which is what people need, is to be defiant. Was that a F sharp I sang or what was it? You know, it doesn't matter.  Speaker 6: Most of them never read poetry before. Most of them never sang before. Most of them never were on stage before. And they were going to put on a show. And they're going to add this other two or three layers of emotional vulnerability.  Speaker 1: All right. Everyone, just like we prepared. We know what we're doing and we're going to enjoy ourselves. Yeah?  Speaker 6: We're doing a concert. People have paid money to come and see us. The adrenaline rush is incredible. I can't describe it really. I never thought I would do something like this.  [Applause]  [Clip ends]  Dr. Dave Johnson: Tell us a little bit about how this film came about. Obviously, you had a personal connection to it. But give us a little bit of background information, if you will.  Mr. Bill Brummel: Well, about nine months after my laryngectomy and after getting through some of the emotional and psychological problems that a lot of people who've had the surgery experience, and we'll go into that later on, I went to an appointment with Dr. Sinha, a regular scheduled appointment. And out of the blue, he suggested that I make a documentary about the psychosocial aspects of recovering from and living with a laryngectomy. Now my first thought was stick to medicine, doc. I'm the professional here. Just kidding. It was an excellent idea. But why on Earth did you suggest that?  Dr. Uttam Sinha: We never get to see the psychosocial aspect or the challenges or the suffering they go through, and most importantly, the head and neck cancer is not so well known in the society, unfortunately. So all my life, in my 25 years of practice, I always tried to promote head and neck cancer awareness in our society. One day I told my friends, 'I need to raise money for research for head and neck cancer.' So they asked me, 'What is head and neck cancer?' I said, 'This is head, this is neck – cancer of this area is called head and neck cancer.  So anyway, so that was one of the driving forces then to create awareness within the society and also how the head and neck cancer patient live after going through the treatment and surviving the cancer.  Mr. Bill Brummel: When Dr. Sinha suggested it, it was an excellent topic. But I knew I needed a story to illustrate it. So right after the appointment, I went home, fired up Google. And very quickly, I discovered the Shout at Cancer choir on a website. Shout at Cancer is a London-based nonprofit charity, that among other things, uses some breathing techniques and singing techniques to improve the vocal outcomes for laryngectomy. Now, I knew that if I could get all the pieces in line, that this would be a great way to produce the film that I wanted to produce, that of a group of people who've undergone a life-altering surgery, and all the hardships and drama that goes with that, but still leading a meaningful and productive lives in a very entertaining fashion.  Dr. Dave Johnson: There's some really extraordinary people in this film from the Shout at Cancer choir. How did you happen to select the specific individuals within that choir group?  Mr. Bill Brummel: Well, I took two production trips to the UK after we found funding and after I got the choir on board. I took two pre-production trips to the UK and went to every choir member's home individually and met with them and their spouses. Now, they all have compelling stories. But for reasons of time, I couldn't have personal profiles on all of them. But I eventually settled on five. And I knew even then, that only four would probably be included in the film. I say that they have compelling stories. I think I could have done a Netflix limited series 10 episodes, one on each choir member.  Dr. Dave Johnson: I think you should consider doing that.  Mr. Bill Brummel: That might be too late to do that. But they're really excellent and articulate and all have slightly different stories.  Dr. Pat Loehrer: You told their stories. And again, for those who haven't listened to the documentary, I really encourage you to do this when this comes out. But just I have a question. You've done so many different documentaries about so many important things over the years. Do you think you would have done this documentary had you not had a laryngectomy?  Mr. Bill Brummel: Definitely not. A laryngectomy was not even on my radar. I don't think I knew what it was before I was faced with having it. So no, I definitely wouldn't have done that.  Dr. Pat Loehrer: It really is a terrific service that you've done. You've helped so many people. Dr. Sinha, there may be a listener or two that listens to the podcast that is not a physician. Can you explain just in lay terms what a laryngectomy is and what it means and the process behind it?  Dr. Uttam Sinha: So, as you know, that larynx is an organ that produces sound. It doesn't produce speech. This a misconception within in our society that the patient undergoing laryngectomy they cannot talk. A laryngectomy patient, they talk well, but the patient when I remove a portion of the tongue for a partial glossectomy, then they have a hard time to speak because speech is produced within the oral cavity.  So a laryngectomy is basically, the removal of the voice box removing the trachea from the esophagus so that they can breathe well and also they don't aspirate because that's a big challenge. Aspiration pneumonia, is a consequence to fibrosis induced by radiation.  So early on in our practice at Keck School of Medicine, 25 years ago, we started this program where we decided to do neuromuscular electrical stimulation swallowing therapy to reduce the fibrosis so that there'll be less chance of aspiration, and aspiration-related pneumonia. So the laryngectomy we perform, especially in Bill's case, he's a cancer survivor, but he had a hard time breathing and talking and also mild aspiration. So that's why we had to do a laryngectomy where we remove the voice box, and that improved his overall quality of life.  Mr. Bill Brummel: I remember as my breathing difficulties increased, Dr. Sinha advised me that a laryngectomy was in my future. And like I said, I didn't even know what it was. But he advised me that my quality of life would improve in the long term. But I was in denial. So I stalled. I didn't have it when he first advised that I have it.  Dr. Pat Loehrer: Here at ASCO, we have 30,000 to 40,000 people there, many of them are cancer survivors, and I'm thinking about when we think about most cancer survivors, Dave is one of them, and we'll talk about that in a little bit, most of them fit in with the crowd. The cancer survivors with laryngectomies something that doesn't. This is something that not only have you survived it, but you have the wounds to show for this. Can you tell us a little bit about that and briefly the thought processes of 'Listen, someone's going to take out my voice box. I'm a director. I need to have this.' I'm sure you stalled making this decision. And what was the final tipping point for you to have this done?  Mr. Bill Brummel: Well, as my condition got worse and worse, it was really hard to speak. And it was really hard to breathe. At times, my wife could hear my labored breathing from the other rooms of the house. I couldn't even climb maybe three or four stairs without getting winded. And then I remember the date of March 10th of 2016. I went to another appointment with Dr. Sinha. And I don't think I got two sentences out before he interrupted me and said rather firmly and with a good sense of urgency, 'Bill, we have to do the surgery now.'  He was obviously concerned that I would have a breathing emergency at home or in the market, paramedics will be called in, they do an emergency trach on me. I knew that Dr. Sinha would do a much better job than a paramedic. But I remember sitting in that exam room with Dr. Sinha and my wife, and the Dr. Sinha was basically telling me I was risking my life if I didn't have the surgery. My wife was worried sick. And although I was frustrated, I couldn't come up with any more excuses. So I said, 'Yes, let's do the surgery.'  Dr. Sinha wanted to admit me right then and there, and not send me home, but the OR was booked on the next day. So Dr. Sinha, bless his heart, called an OR to come in to do the surgery on a Saturday. I was the only one in the recovery room or the pre-op room. And I remember that when we arrived at the hospital, I think we have a clip of our kids, my wife, and I, we were sitting in the admissions waiting room. And my wife got out her cell phone and asked if she could record my natural voice, although wheezy and weak, one last time. And this is the 35 seconds.  [Recording starts playing]  Frances Fitzgerald: Okay. What's happening today?  Mr. Bill Brummel: It's 5:30 in the morning, March 12th, 2016. And today, I'm giving away my vocal cords. And walk out of here, hopefully within a few days, with voice prosthesis and a new voice. Although I won't be able to test the voice for several weeks, I'll have to be silent, which will please many people around me. So that is what is happening. Last time you'll hear this voice. So to all of you, I love you. Thank you for all your support and prayers. Here we go.  [Recording stopped]  Dr. Dave Johnson: So I'm sure that that probably brings back some very emotional memories to you, Bill, and as Pat asked, post-operatively, what did you think about your future? What was your psychological state at that time? And how did you feel physically?  Mr. Bill Brummel: Well, physical recovery from the surgery was hard. And I vacillate by saying it was hard and it's awful, but it was physical recovery. But worse yet, I was saddled with insecurity and fear and doubt. People who have had the surgery can often lose confidence. They can sometimes retreat from society and withdraw into a world where we don't have to be seen in public. But when we do that, lonesomeness and depression are sure to follow. There were times I found it easier to isolate myself rather than navigate. I didn't want to go out. I didn't want people to see me. And I got depressed. It was just natural. Losing your natural voice is really traumatic. From the time we learn to speak, much of how we perceive ourselves is wrapped up in the unique tone of our voices. It expresses laughter and happiness. And with that gone, many patients really struggle with anxiety, self-doubt, and doubting their self-identity.  Dr. Dave Johnson: So, Dr. Sinha, is that a common reaction amongst your patients post-surgery?  Dr. Uttam Sinha: Yes, it's fairly common. That's why I started 16 years ago with my colleagues a survivorship program to support the psychosocial aspect of these patients. Whenever we can, we mentor the newly diagnosed patient with the established patient. Bill has done many, many mentoring for those patients who underwent laryngectomy after his laryngectomy. And I'm so grateful that our patients are so supportive to each other for the whole organization. So yes, this is very common and that's why we always talk about not just the physical but psychosocial aspects of our health. And also in our practice, we always try to promote not only the health of the patient but also health of the caregivers and the family to improve health. I think it depends on all four dimensions of health, which is the WHO definition of health, the best state of physical, mental, spiritual wellbeing, and not a mere absence of a disease process.  Dr. Dave Johnson: You mentioned the family. We want to get back to that in a moment. I think we have a clip from Sara. She was one of the patients that was featured in his film, and there's a wonderful clip. I want to get to that in just a moment. But I just have an important question to ask Dr. Sinha. Was Bill a good patient?  Mr. Bill Brummel: Was I a good patient?  Dr. Uttam Sinha: I have to think about that.  Dr. Dave Johnson: That's what I thought. We'll watch this clip while you think about that.  [Video clip playing]  Sara Bowden-Evans: I have two vivid memories of those moments just before going down to theater and having the realization that when I came back out, I wasn't going to be the same person. I would never be me again because they would taken my personality which would mean my voice. And then when I came around, I couldn't call for help. And that was so frightening, really scary.  That was pretty awful actually coming to terms with all of this. I lost all my confidence and didn't want to speak. You can sound very angry all the time, even when you're not. I didn't want anybody else to really see me or hear me and all the other things to contend with as well, not being able to swallow properly and losing all my taste with radiotherapy, suddenly gone. I think the loss of laughter is one of the most difficult things for me. So it's just one thing after another after another and it just made me angry all the time.  Speaker 7: Emotional changes were quite dramatic. She was very, very moody at times. She just felt that everybody was staring at her. And it just changed her personality.  Speaker 8: We know from evidence that people who've had a laryngectomy can be much more likely to experience anxiety, depression, social withdrawal that can have a really important impact on relationships.  Speaker 7: The emotional side is the hardest part of caregiving. That's part of a relationship. You take the bad times with the good times.  Sara Bowden-Evans: I know that I wasn't a very good patient because I know that there were times when I was really horrible to him because I was dealing with my situation, and I took it out on him. But he's still here. He stayed with me regardless.  [Video clip stopped]  Dr. Pat Loehrer: As you watch this film, you realize what a remarkable human being Sara is. She's a writer, she's a poet, and even the title of your documentary comes from her.  Mr. Bill Brummel: I stole it from her.  Dr. Pat Loehrer: Yeah, it's extraordinary.  Mr. Bill Brummel: It's one of the poems she wrote and we use in the film.  Dr. Pat Loehrer: The question I'd asked Dr. Sinha, if you don't mind just following up on this, when a woman is diagnosed with breast cancer, as my wife was, there's this wonderful support community, and they even have a color of their own. And the women get together and they have runs and they do all the stuff. Similarly for several other cancers. I think with head and neck cancer, the inclination, I think, as Bill mentioned earlier, is to be isolated and almost withdraw yourself. This was a unique group of individuals that got together for this project. We'll hear about it more. But how common is it for laryngectomy patients to actually bind together? Or do they typically fight this battle alone?  Dr. Uttam Sinha: So they feel very isolated, no question, and depressed. That's why it's very important to have that kind of support system. Head and neck cancer is very unique. Most other cancers, squamous cell carcinoma, the same cancer when it happens in the lung, and you remove half of the lung, nobody would know and person's quality of life would not be compromised.  On the other hand, if same squamous cell carcinoma happens in the head and neck area, it compromises quality of life because all the function that makes us human beings - speech, swallowing, hearing, balance, smell, taste, all those things happen in this area. So when this area is damaged, whether by cancer itself or treatment related, that causes tremendous depression as their functional status goes down, and also they get isolated because they cannot go to the society freely, like to go to a restaurant and feeding himself with a G-tube with the rest of their friends or family are eating by their mouth. So that's quite depressing. In fact, I have patients, couple of patients who committed suicide because they were G-tube dependent. So head and neck cancer in that regard is very unique compared to other cancers.  Mr. Bill Brummel: I would say, to just add one point in regards to Sara and other women who have a laryngectomy, obviously, we don't have a lot of breakage in our voice. Our voices are very low. And it's really the same for women as it is for men. But men's typical voices are lower and women's are not. So that is a factor in their emotional recovery. They really don't sound how they used to when speaking with a voice prothesis or through an electrolarynx. So it's really difficult for women.  Dr. Pat Loehrer: As humans, we think in the past and the future, we go back and forth, but you've had a life as a very successful film producer, director. And I think in many ways, this is probably one of the most unforgiving professions for any kind of disability, whether it's even putting on some weight or having an accident. But tell me a little bit about your life before laryngectomy and after laryngectomy. How has this changed your life as a professional? What has happened?  Mr. Bill Brummel: Well before even my laryngectomy, before cancer, I was originally diagnosed in 1997 with tonsil cancer. It was treated by neck dissection, not by Dr. Sinha, and seven weeks of radiation antidotes over wide fields. I had been in television production for about 10 years prior to that. And I was doing mostly silly reality shows, or music video shows, stuff that didn't have really any substance to it. I had started my own production company about a year before, but after my cancer diagnosis, I really thought to myself that if, God forbid, the cancer comes back and my life is cut short, do I want to spend my days, my effort in terms of my work life producing shows with no substance. And I said, 'No, I don't want to do that. I want to produce shows that feed the soul as much as the wallet.' Unfortunately, 20 years after that, my soul got a lot better than my wallet. But I wouldn't change it for the world. But having cancer, having that diagnosis definitely changed the trajectory of my career. I wanted to have a legacy and something that my children would be proud of.  Dr. Pat Loehrer: Just a follow-up question, I had a very good friend of mine who had a glioblastoma. After his diagnosis, he said he learned things about friends. He said, there were three kinds of friends. There were these friends who were the loyal friends who he'd always had, who really were with him. There were the people that he had thought were friends that just disappeared. And then there was a third group of people who we never ever dreamed would be friends, but they came out of nowhere to become new friends for him. So reflect a little bit on that. Does that resonate at all with you?  Mr. Bill Brummel: It definitely resonates. After my laryngectomy, and I went through this period of emotional difficulty, I was still one of the fortunate ones. I was blessed to have a supportive network that included family and friends, others, colleagues aided my recovery. And obviously, the medical team at Keck Medicine of USC, a lot of them became my friends and are still my friends. So they came out of the woodwork. My laryngectomy buddies are close friends. We have a supportive group that meets two times a month. They become real good friends. I can't imagine my life without them. But Dr. Sinha talked about his supportive care. It was really important to me. He's always preached about a hollistic response approach to health that includes traditional medicine, exercise, nutrition, physical therapy, mindfulness, and a bunch of other things, occupational therapy, speech therapy. To varying degrees, I embraced each of those modalities. But back to your original question, certainly, some friends fell off the map. I made new ones, the family and friends that I had, the relationships became really strong and a really important and critical part of my life.  Dr. Dave Johnson: That certainly resonates with my own experience as a cancer survivor as well. And you've mentioned your family more than a few times. I'm confident that they were a very important part of that support system. Could you speak to that a bit?  Mr. Bill Brummel: Well, they understood what I was going through. And if they didn't understand, they asked questions. They didn't ignore the elephant in the room. My wife, as a caregiver, I really don't know what I would have done without her after my laryngectomy. She was changing all my dressings, cleaning out the stoma, stuff that I assume if I was alone, I could have done it, but I didn't want to. I didn't want any part of it. So she got me the physical recovery. And then she started getting me the emotional recovery.  When I was feeling sorry for myself and sitting at home, she very politely kicked me out of the house. And she said, 'If you want a cup of coffee, you get it.' I would drive down to Starbucks. It took me three months to speak because the swelling wasn't going down. But she kicked me out of the house and said 'Go to Starbucks' And I would just write on my phone my order and show it to them. And that seems like a very easy thing to do, but it was a big step for me.  But it also started me thinking, well, maybe people are going to stare. But it seems like most people are understanding. And that's been my experience. I get stared at a lot all the time. And when I speak, people turn their heads. But most people are really understanding and want to help. In fact, they might even take the extra step for me that they wouldn't for some other person.  Dr. Uttam Sinha: We established a caregiver support group, Coffee with Caregivers, and Frances is the president.  Mr. Bill Brummel: Frances, my wife, yes, she facilitates the weekly meetings.  Dr. Dave Johnson: Well, there's so many rich aspects of your film. For those who have not seen it, you really do need to see this film. But there are a couple of areas that really resonated with me and reflected my experience, one of which we have a clip from this family. But I have a daughter, who was 10 at the time that I was diagnosed with lymphoma. And my wife and I did our best to shield her from the possibility that I might not survive that. In retrospect, I'm not sure we handled it quite the right way. But you have a clip from Pug and his wife, Kat, and their daughter, Lily. And I think it so reflects my own personal experience with my daughter and her reaction to me. So maybe you might want to just comment on that before we show the clip.  Mr. Bill Brummel: In the pre-interviews I did and selected a choir member for shooting, I developed an outline of what I thought the segment with life would look like. And you know when you do documentaries, you had to be able to change it at a moment's notice. So I had three interviews with Pug and Kat and came up with a sweet story that involves just them. When we recorded the interview, I was just blown away by Pug's daughter, 12-year-old Lily, and completely changed the focus of Pug's presence in the film to illustrate the impact that a cancer diagnosis and a laryngectomy has on families.  [Video Clip Playing]  Interviewer: When your dad got the laryngectomy, how did you deal with it?  Lily: I think I was probably more upset than dad seemed because I thought he was really going to die.  Pug Halliday: It's hard because we were always honest with Lily. But no matter how many times we said it was going to be all right, you know, you were worried, weren't you?  Kat: Basically after the operation, Pug had a lot of black, like Frankenstein stitching and drains and tubes. And Lily hadn't really seen that sort of thing before. Because she was younge,. I didn't want her to be frightened, so I waited and I spoke to Pug. 'When shall I bring her up?' And he said, 'Why don't you take a photo?'  Pug Halliday: The drain's around, so that would be five, seven days after my operation.  Mr. Bill Brummel: And Lily, so that didn't scare you, the photo?  Lily: No, because he was—well, I think that yeah, it scared me a little bit, but in that photo, he's like really happy, so-  Pug Halliday: By the time when we asked Lily, she said, 'You were smiling and had both thumbs up.' So, you were reassured a bit by that, weren't you?  Lily: Yeah.  Mr. Bill Brummel: Lily, what did you do to try and make your dad feel better during his recovery?  Lily: I made tea for him.  Pug Halliday: Yeah, you came and you read me stories instead the other way around.  Lily: I read you stories, and I made him lots of things as well. Like, I don't know, like little books where he was really amazing.  To you, my favorite person in the world.  You are the best.  You're my inspiration.  I love your facial hair and your mustache presentation.  When you were ill, feeling depressed,  I knew you'd make it because you're the best.  You're kind.  You're brave.  You're funny, too.  I'm so happy I have you.  I can't believe that you're my dad.  It turns out that you're not so bad.    [Giggles]  Pug Halliday: I keep these by my bed. And when she turns into a teenager and hates me, I shall read them regularly.  [Video clip stopped]  Dr. Dave Johnson: If that poem doesn't melt your heart, you have a heart of stone.  Dr. Pat Loehrer: What you can't appreciate on a podcast this incredible poem. It's just incredible.  Mr. Bill Brummel: He's a marvelous character. You know, you're mentioning your daughter, my daughter was eight years old. And my son was five-and-a-half in terms of when I had my original cancer diagnosis. In fact, we celebrated his sixth birthday in the hospital. On the last day of my radiation treatment I had to be hospitalized three times because I couldn't keep anything down. But my daughter commented, this was when she was graduated from high school, I think, that she really thought that I was going to die. And we said no such thing. In fact, like Pug, we tried to reassure her that my tonsil cancer diagnosis was not life-threatening. But in her mind, she remembers it as being a case that my dad might die.  Dr. Dave Johnson: Yeah, my daughter reacted the same way. And she kept a diary at the time. When we went back and read her diary, she actually wrote, 'My dad is going to die.' Yeah. The other clip that really stood out to me also involved a poem, and it comes from Sara. Sara is a real star in this. It's a poem to her husband, Nigel. It's a cancer survivor's reflection on how they dealt with their cancer and their spouse during the intensity of the treatment. I wonder maybe if you could make a few comments and maybe we could show that clip.  Mr. Bill Brummel: Well, definitely. The spouse or partner, the impact can be great. And in Sara's case, in her words, she took out her frustrations on Nigel. And Nigel was a great caregiver and just dealt with it and never stopped loving her. Interesting thing about this poem, it was not a poem for the choir. It was after we finished shooting one of the rehearsals. I was talking to Sara, and she casually mentioned that, “Oh, I've written a poem to Nigel, but I'm scared to show it to him. Like he hasn't seen it or heard it.” And being a film producer, I said, “Wait. Don't read it to him. Don't show it to him.” We were scheduled to go out and shoot the segment with her at her home in a week or two. So I said, 'If you would read it on camera, I would love you forever.' I would have loved her forever anyway. So what you see, it's almost one take of her reading the poem to Nigel. And none of us in the room, of the crew and me, Nigel, had ever read the poem. And Nigel had never heard of the poem.  Dr. Dave Johnson: This is very real and in many ways, raw. I think it really illustrates that relationship. Again, not to talk about my own illness, but I felt the same way Sara did.  [Video clip playing]  Sara Bowden-Evans: So I need to read you something.  Nigel: You need to read me something?  Sara Bowden-Evans: Yeah.  Nigel: Go on then.  Sara Bowden-Evans: I wrote another poem that is for you.  Nigel: For me?  Sara Bowden-Evans: Yeah. I'm going to try to read it very easily now.  Nigel: When did you write this? Kept that very secret.  Sara Bowden-Evans: Because I don't know how else to say what I needed to say.  Nigel: Okay.  Sara Bowden-Evans:  I'm sorry for the pain I caused.  I'm sorry for the hurt.  You were always in the firing line  To take the brunt of course  It's not that I'm actively directing it to you.  It's just you're the one that's always there.  And that's the truth.    They say we always hurt the ones we love.  And there's a reason.  And that's because the ones you love the most know all your feelings.  You've suffered with me.  All the pain, the sadness, and my darkest days.  You forgive whatever nastiness I throw.  But I don't know how to ever repay all the things you've done,  apart from writing down in words.  Nigel: That was so beautiful. Thank you. That's amazing.  [Video clip stopped]  Dr. Dave Johnson: I know that there are no words that can describe that.  Mr. Bill Brummel: Yes. Sara really is the emotional center of the film. And from a producer's standpoint, I don't mean to sound crass, but you always can get behind a person cry on camera.  Dr. Pat Loehrer: When I was watching the movie, though today, could you get behind me because I was crying.  Mr. Bill Brummel: Well, I usually, at any public screenings, and because of COVID, there hasn't been a lot of them, but I try and view the film from the back of the audience. And I'm scouring the audience to make sure they're laughing or crying at the appropriate places. And they usually are.  Dr. Dave Johnson: So Bill, what message would you like for oncologists to take away from your documentary?  Mr. Bill Brummel: Well, very simply. It's the message I would like oncologists to hear and implement, and a lot of them do, but it's to treat the patient and not just the disease. And that's it in a really simple form. The psychosocial consequences of any cancer diagnosis are challenging, and especially as Dr. Sinha said, in head and neck patients, where the treatments often leave a patient disfigured in a noticeable and visible way. Shame, anxiety, and depression are common enemies. Support the psychosocial health of your patients. And I'm convinced that if you do that, their physical condition will improve.  Dr. Pat Loehrer: Well said. We certainly can't let you out of here without showing a clip from the choir's performance at the concert that you filmed. In fact, there were several, several songs. I think we're going to show one of them there. But can you tell us a little bit about the film distribution plans, the business of this, how will the public be able to see this film? What's happening on that end?  Mr. Bill Brummel: Well, we have a commitment from PBS if I want to show it on the PBS network of stations. We're aiming for a 2023 broadcast, probably spring. Currently, I really want to maximize the impact the film will have with the general cancer community. And for the last six months or so, we've initiated impact and outreach campaigns. And by that I mean we're doing branded screenings and webinars and speaking and showing films at conferences. We're aiming at the cancer advocacy and support communities, universities, medical schools, clinician associations. We've done a bunch so far. We're doing more. We're also trying to partner with corporations or nonprofits to bring these screenings to cancer advocacy and organizations that might not be able to afford a screening. And we're looking for underwriters with the PBS podcast. But the film will get out there. I just really, for the time being, want to concentrate on the cancer community.  Dr. Pat Loehrer: That's terrific. So we're going to show a one of the performance clips. Do you want to set that up for us, there.  Mr. Bill Brummel: COVID shut down the choir. So every time I see a performance, it makes me long for more and more performances. But this clip is as rendition of Ain't Got No, which was popularized by Nina Simone in the ‘60s. It was originally written for the musical 'Hair', but one of the unique things about the choir is that they at times rewrite lyrics to songs to make them more illustrative or the lyric to explain the full impact of having a laryngectomy. So this is the song we're playing last, it's the finale of the concert and the film. The first half of the song speaks to all the things we've lost by not having a voice box. Second half, which we'll see, speaks to all the things we still have, can still do in life. Sara helped adapt the words. It was a group effort.  [Video clip playing]  Singer: [singing] What have I got? Why am I alive anyway? Yeah. What have I got? Nobody, nobody can take it away. I…  Choir: [singing] got my hair, got my head, got my brains, got my ears, got my eyes, got my nose, I got my mouth. I got my smile.  Got my health, got my tongue, got my teeth to make these sounds, in my head I change my breath, I got control. I got voice. I got poems, I got friends, got my songs, got my limbs, got my heart, got my soul, got my pride.  I got my voice.  Opera Singer: [singing] What have they got? Sing, what have they got?  Choir: We've found our voice.  [Applause]  [Video clip stopped]  Mr. Bill Brummel: Obviously, the woman that sang at the end did not have a laryngectomy. She's a professional opera singer.  Dr. Dave Johnson: I think I can safely say, for all of us here today, that we thank you for producing such an inspirational film, and one that really I think captures the emotions that go along with, one, being diagnosed with cancer, two, going through treatment, three, experiencing survivorship and the support. And Dr. Sinha, to you, thank you for inspiring Bill to doing that.  We have maybe just a couple of minutes if there any questions from the audience. We haven't received any via the text. So if there's any questions, there's a microphone here. And as an added incentive, if you ask a question, you get a free Oncology etc. t-shirt.  Dr. Pat Loehrer: Better yet, we may not give them. That might be a great incentive.  Dr. Dave Johnson: Don't trample one another running to the microphone. I see, there are people who want their t-shirt. So please.  Question 1: Thank you so much. That was a beautiful film. I'm a nurse, and it's a great inspiration. And I'm sure it's a great inspiration to the patients. Are there any similar organizations in the United States doing a choir?  Mr. Bill Brummel: Not that I know of to the extent that Shout at Cancer does. There's several laryngectomy support groups or laryngectomy clubs around the United States. And every once in a while, you'll see one that the patients get together and sing for fun or they do a Christmas performance at some event. But Shout at Cancer takes it really to an unheard of level. I've never heard of anybody doing this in the world as much as they do in terms of the original writing, the professional musicianship, the rehearsal. So I'm not aware of any that take it to that extent.  Dr. Pat Loehrer: I just want to say from my own behalf, we're in this world. The best thing you can do at the end of your life is to say that you made a difference. And this film, what you have done has made a difference. As long as I have the capacity to remember, I will remember you and I will remember this film. So thank you very much.  Mr. Bill Brummel: You're welcome. And thank you for saying that. I'm touched. And that exactly was the point. I think that was the point when Dr. Sinha said, 'You should do a documentary about the psychosocial effects of having a laryngectomy recovery and living with a laryngectomy.' I don't know that he thought I'd do it to this extent, but that is the message I want to inspire people who've had a laryngectomy, and I want the world to know and to relate better to people and understand people.  Dr. Uttam Sinha: That gives me a lot of joy in what it means to recognize leaders like you and the society of head and neck cancer patients. And Bill has been a driving force for me to stay in head and neck cancer surgical oncology care.  Dr. Pat Loehrer: The world's a better place because of both of you.  Dr. Dave Johnson: Yeah, for sure.  Dr. Pat Loehrer: For those that were here in the audience and those at home, don't forget, you can claim credit for this. Provide feedback. And if you could, I really would like to have a little bit about who's the best-looking podcaster, if you could.  Dr. Dave Johnson: I think that's critically important. And I appreciate Dr. Sinha's recommendation. It's made me rethink my take two aspirin and call me in the morning recommendations. So I'll have to be more productive in the future.  But this brings us to the end of this podcast. I don't know if any of you in the audience have listened to our previous Oncology, etc. podcasts. We hope that you did. And we hope that you will. As we've said at the end of each of our podcasts, we welcome ideas. We will literally talk about almost anything oncology related or not. That's why we have the 'etc.' on and it's been a great joy for Pat and me. Both of us enjoy doing this. We've been great friends for over 40 years. And it's a wonderful way of cementing the friendship.  So thank you for all of you who are here in the audience. It'll take about an hour to file out with this large crowd so please be careful as you move to the doors. Thank you.  Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org.    The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   

Oncology Today with Dr Neil Love
Key Presentations on Breast Cancer from the 2022 ASCO Annual Meeting with Dr Angela DeMichele

Oncology Today with Dr Neil Love

Play Episode Listen Later Jul 18, 2022 45:49


Dr Angela DeMichele from the University of Pennsylvania in Philadelphia discusses key abstracts in breast cancer presented at the 2022 ASCO annual meeting. CME information and select publications here (http://www.researchtopractice.com/OncologyTodayPostASCOBreast22).

Breast Cancer Update
Oncology Today with Dr Neil Love: Key Presentations on Breast Cancer from the 2022 ASCO Annual Meeting

Breast Cancer Update

Play Episode Listen Later Jul 18, 2022 45:52


Featuring a discussion on abstracts in breast cancer presented at the 2022 ASCO annual meeting with Dr Angela DeMichele, moderated by Dr Neil Love.

Transmite la SER
Transmite la SER | El asco del poeta, con Javier Cansado

Transmite la SER

Play Episode Listen Later Jul 17, 2022 51:56


José Luis y Javier Cansado nos vuelven a visitar en el último programa de esta primera temporada. La radionovela tampoco falta a su cita con oyentes muy especiales e Ignacio Crespo que también sabe mucho del telescopio James Webb.

The ASCO Post Podcast
ASCO 2022: Conversations in Genitourinary Oncology

The ASCO Post Podcast

Play Episode Listen Later Jul 15, 2022 19:15


In this episode, we're featuring two conversations from leaders in the field of genitourinary oncology. These discussions go over long-term findings in prostate cancer and urothelial carcinoma, and were both presented at the 2022 ASCO Annual Meeting. To listen to more podcasts from ASCO, visit asco.org/podcasts.

EVTV EN PODCAST
#Editorial | #EntreFuerteYDulce | Asco y miedo | Al Mediodía | 14-07-22

EVTV EN PODCAST

Play Episode Listen Later Jul 14, 2022 11:20


Jessica Vallenilla y Carlos Acosta comparten su editorial este jueves 14 de julio de 2022 --- Support this podcast: https://anchor.fm/evtv-miami/support

ASCO Daily News
Hidden Gems From ASCO22: Abstracts on EDI, Health Care Economics, and More

ASCO Daily News

Play Episode Listen Later Jul 14, 2022 8:17


Dr. Pamela Kunz, of the Yale Cancer Center, and the JCO consultant editor for Meeting Abstracts, discusses “hidden gems” from ASCO22, highlighting abstracts that address EDI, global health, health care economics, and more. Abstracts/Tweetorials @PamelaKunzMD and @ryangentzler TRANSCRIPT ASCO Daily News: Hello, and welcome to the ASCO Daily News podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. My guest today is Dr. Pamela Kunz, an associate professor of medicine and director of the Center for Gastrointestinal Cancers at the Yale School of Medicine. Dr. Kunz is also the Journal of Clinical Oncology's (JCO) contributing editor for meeting abstracts. You may have seen her recent tweetorials highlighting compelling abstracts from the 2022 ASCO Annual Meeting. She'll be telling us more about this initiative to highlight impactful studies that address equity, diversity, and inclusion, global oncology, and more. Dr. Kunz's full disclosures are available in the show notes and disclosures relating to all episodes of the podcast can be found on our transcripts at asco.org/podcasts. Dr. Kunz, thanks for being on the podcast today. Dr. Pamela Kunz: Thank you. It's my pleasure to be here. ASCO Daily News: Social media has created a global community in oncology, and you and Dr. Ryan Gentzler of the University of Virginia Cancer Center recently launched a great series of tweetorials to highlight compelling studies from the ASCO Annual Meeting. Some of our listeners will have seen these threads already, and others will be keen to find them and know more about these efforts. Can you give us the details? Dr. Pamela Kunz: Sure, I'd be happy to. This is a new initiative to really modernize the meeting abstracts. These used to be called meeting proceedings and were printed, and we felt that there was a real opportunity to use social media to disseminate more information around abstracts. And we decided this year to focus on four themes. They are diversity, equity, and inclusion; global health; health care economics; and the Merit Award recipients. And within each of these tweetorials, we have 4 to 5 abstracts that are highlighted that include takeaways and a visual from the poster or presentation. We intentionally decided to highlight abstracts that were not otherwise highlighted in the ASCO Annual Meeting in either oral sessions or poster discussions. So we are calling these hidden gems. There are so many great scientific abstracts that don't get otherwise highlighted, and this was a really nice opportunity to do so. ASCO Daily News: Excellent. And I understand you'll be highlighting a couple of abstracts for us today. I believe the first one concerns telehealth used by older patients. Can you tell us about this abstract? Dr. Pamela Kunz: Sure. So this is in the health equity tweetorial, and this is Abstract 1591 by Dr. Higashi and colleagues. And the takeaway from this, I found this interesting, and the disclosure is that I selected these abstracts, given my own personal interests, but I thought that they would be of broad interest to the ASCO membership. So telehealth really became used quite often during COVID, and I think that that has been a real silver lining that there is increased access to expert cancer care through the use of telehealth. This abstract demonstrated that the use of telehealth during cancer treatment was really received positively by older patients, providers, and staff. Most older patients, 66%, and providers and staff, 77%, intended to continue using telehealth after the pandemic. There are certainly some equity issues related to telehealth in terms of access to the internet and the ability to use the technology, but I thought this was interesting because it's specifically focused on older patients. ASCO Daily News: Excellent. Telehealth certainly has been a gamechanger in oncology. I believe the second abstract that you'll be highlighting addresses the use of supportive care in pancreas cancer, correct? Dr. Pamela Kunz: That's exactly right. So this is in the Merit Award tweetorial, and there are so many fantastic Merit Award recipients. It was actually very difficult to select just a few to highlight. In the tweetorial, we will be providing the link to all of the Merit Award recipients. So I encourage listeners to really go look at that. So this specific abstract that I wanted to mention on today's podcast is Abstract 4154 by Dr. Chris Cann and colleagues. They examined, through the National Cancer database, over 150,000 patients with locally advanced pancreatic cancer and found that only 2.9% received supportive care treatment despite over 65% of these patients receiving care at an academic program. And so I think that it just really highlighted the need for these patients to really utilize supportive care programs. Perhaps sometimes we have a bias that we refer patients with metastatic pancreatic cancer to supportive care programs. But there's an opportunity to take advantage of these services earlier. ASCO Daily News: Excellent. Well, Dr. Kunz, looking ahead, do you think there's scope to leverage social media more in oncology? Tweetorials, for example, are a great vehicle for education and a way to address topics that don't get as much attention as we'd like? Dr. Pamela Kunz: Absolutely, Geraldine. You know, this was a pilot this year with Dr. Ryan Gentzler and myself. There is an active social media editor, Dr. Shannon Westin, who's a consultant member of the JCO editorial board as well. I think in partnering with the ASCO Annual Meeting Social Media Team, this has really been a team effort. And we are hoping to do more of this in future years, and in particular, take advantage of creating opportunities for perhaps fellows and junior faculty to assist in disseminating some of this information via social media. ASCO Daily News: Absolutely. This is an incredibly important initiative that will benefit oncologists, patient advocates, and patients alike who are on social media to learn about advances in care. So it's really important that we let our listeners know where they can find these tweetorials. You are on Twitter @PamelKunzMD and Dr. Ryan Gentzler is @ryangentzler. Dr. Kunz, is there anything else you'd like to add before we wrap up the podcast today? Dr. Pamela Kunz: Well, thank you for the opportunity to highlight this. I think we would also welcome suggestions from our listeners. If you are reading the tweetorials, you can send me a direct message, and we'd welcome suggestions for future years on how to highlight other science from our ASCO Annual Meeting. ASCO Daily News: Absolutely. And we'd certainly like to encourage our listeners to share these amazing tweetorials. Well, Dr. Kunz, thanks for coming on the podcast today and for your efforts to elevate abstracts and investigators who are working really hard to address some complex issues in cancer care. Dr. Pamela Kunz: Thank you for the opportunity. ASCO Daily News: And thank you to our listeners for joining us today. You will find links to the abstracts discussed today on the transcript of this episode, and we'll post the Twitter handles of Dr. Kunz and Dr. Gentzler in the show notes. Finally, if you value the insights you hear on the ASCO Daily News podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. Show Guest Pamela Kunz, MD Ryan Gentzler, MD Tweetorials: By Pamela Kunz, MD Health Equity/DEI Merit Awards By Ryan Gentzler, MD Cost & Financial Hardship Global Health Disclosures: Dr. Pamela Kunz: Stock and Other Ownership Interests: Guardant Health Consulting or Advisory Role: Ipsen, Lexicon, SunPharma, Acrotech Biopharma, Novartis, Genentech/Roche, Amgen, Crinetics Pharmaceuticals, RayzeBio, Natera, HUTCHMED Research Funding (Inst.): Lexicon, Ipsen, Xencor, Brahms (Thermo Fisher Scientific), Novartis Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

ASCO eLearning Weekly Podcasts
Cancer Topics - Career Paths in Oncology (Part 2)

ASCO eLearning Weekly Podcasts

Play Episode Listen Later Jul 13, 2022 20:46


In part two of this two-part ASCO Education podcast episode, host Dr. Jeremy Cetnar (Oregon Health & Science University) continues the conversation with Drs. Lauren Abrey and Jason Faris, whose careers have criss-crossed academia and industry. They share words of advice for trainees today. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT Dr. Jeremy Cetnar: Hello, and welcome to Part 2 of the ASCO Educational Podcast episode focused on career choices and transitions. My name is Jeremy Cetnar. I'm a Medical Oncologist and Associate Professor of medicine at Oregon Health and Science University in Portland. In Part 1, Dr. Lauren Abrey and Dr. Jason Faris about their motivations for pursuing medicine, and how they arrived at the different positions they've had. Today, we'll further explore career fulfillment, maximizing impact on patient care, and differences between working in academia and industry. Dr. Faris, what have you learned from the different roles you have had, and what aspects of your current work do you find most rewarding? Dr. Jason Faris: So, there's a lot to discuss here. In my academic and patient care roles, I felt extremely privileged to forge strong bonds with patients and their families, to offer support, counseling and hope in the context of making really difficult, challenging decisions... to rejoice in the individual victories, whether that was clean scans and normal tumor markers after adjuvant therapy for Stage III colon cancer, using the neoadjuvant therapy in locally advanced pancreatic cancer and watching them go to resection, helping to maintain quality of life by addressing key symptoms that a cancer patient unfortunately must endure, and providing emotional support when things do not go as hoped. Whereas the latter times in GI cancer patients are unfortunately all too common. And the moments or clinic visits where the cancer has recurred, or the treatments aren't working really do take their emotional toll on clinicians. I'll just say I took many of those losses personally. And as a general rule in medicine, I tend to wear my heart on my sleeve, which can be a mixed blessing. But that shared sense of purpose and the many times where you were able to offer something meaningful to patients and families provided real fulfillment and joy. I think at the time of the two transitions I've had, this was fundamentally the most difficult part for me, which was relinquishing these direct patient care interactions. So, another highly rewarding part of my role in academia was working with colleagues to open clinical trials or conduct clinical research. I had opportunities to be mentored by or collaborate with multiple people Ted Hong, Dave Ryan, Chin Wu, Jeff Clark, David Ting, and others at Mass General, as well as Lionel Lewis, Konstantin Dragnev, and Steve Leach at Dartmouth. Treating patients on clinical trials was always a stressful enterprise but highly rewarding, and I had the chance to be part of some really amazing groundbreaking trials at MGH, in some cases witnessing breathtaking responses in patients who were out of treatment options, in some cases for many months. Another highly rewarding aspect of my role in academia or my roles in academia involved all of the many opportunities to engage in teaching and mentoring, whether that's with medical students, residents, or fellows, where the enthusiasm for helping patients and learning was always infectious. Finally, I'd be remiss not to mention the wonderful nurse practitioners that I've worked with like Patty Tammaro at Mass General, with whom I cared for many GI cancer patients for years, and Elizabeth McGrath at Dartmouth, whose wisdom and dedication to patient care was really inspiring. On the industry side, on the NIBR side, I've had the opportunity to work on novel therapeutics that are making a bench to bedside transition from a drug candidate to a first in human Phase 1 trial, which to me is a thrilling, complex, and highly fulfilling endeavor that contributes critical knowledge to advance the field. And in the best of cases, identifies therapies that has the potential, that have the potential to alter the prognosis for thousands of future patients. As a clinician or clinical investigators, those times where your patients are responding to their treatment, whether it's on or off a clinical trial are wonderful and so incredibly rewarding. And I would argue that there's a similar phenomenon in running trials in industry, where there's nothing quite as magical as having a cadre of patients who had run out of treatment options, enrolled to a clinical trial designed based on compelling science, go on to experience sustained and significant responses. I absolutely love the commitment to patients and to follow the science, the collaborations among our teams, and interactions with our academic colleagues which I really treasure. I'm part of a team whose responsibility is to ensure the development of a clinical protocol to safely evaluate the potential of that therapeutic, carefully monitor for adverse events, evaluate the emerging pharmacokinetic and pharmacodynamic data, and most fulfilling of all, begin to observe responses in patients whose cancers had progressed on standard of care therapies. So I think the chance to have an opportunity to explore new therapeutics that might impact the eventual treatment of thousands of people with cancer is what keeps me engaged and fulfilled. It's been a wonderful opportunity and applies the clinical skills and patient focus from my prior roles and combines this with the resources and expert teams to run and analyze clinical trials. Dr. Jeremy Cetnar: If I can opine a little bit and ask you guys some philosophical questions. I think what I'm hearing today and what I've heard from other folks who have made that transition is that in industry versus academics, you work in a team, and you're evaluated as a team. And that's very different than in academics. You're very much rewarded for, whether it's patient volume or number of papers or leadership. That seems to me like a very big difference in terms of academic versus industry. And I'm wondering if you guys can comment on that a little bit more. Then you guys also mentioned, at least you just mentioned this, Dr. Faris, is that some will also say that when you go into industry, you're able to just impact a much bigger population of folks rather than typically in an academic setting where you are working one on one with patients. And yes, you have your IETs and whatnot, but there's just a bigger vision. Would you say that those are two accurate differences that are fairly significant, Dr. Abrey? Dr. Lauren Abrey: Yes. You are certainly part of a team. But I think if we're honest, you're part of a team when you're in the hospital. So I ran the team of research nurses. I ran the fellowship program. I needed people to manage the patients who were in-patient and to help me look after the clinical trial conduct paperwork, etc. and so I think that does translate into the setup that you find when you move to industry. It may be a little bit that your personal success, and industry can get very sometimes focused on metrics, like what have you contributed? What has the team been successful? So you do need to think about how to set yourself up for success. If you're leading the team, how do you set the team up for success? To me, that doesn't feel terribly different than academic medicine, but I could see where it could be a change depending on what your role was in the academic world. So I think that's reasonable. The other part of what you said, I struggle with that sometimes. I feel like we tell ourselves, that we're impacting more patients. And I think that's true. If we get a drug approved, and potentially that drug is used, not only in the US, but across western countries, in Europe, potentially in China, you get a sense of that. But it's like how do you feel that? You feel the story of an individual patient. Sensing the scale can be hard. News media know this well. They often tell the story of a particular person in the Ukraine right now to try to help us understand the scale of the war, because otherwise, it's a little impossible to digest. So for me, that doesn't always resonate. I think it resonates when I go out and talk to the different physicians practicing in different parts of the world. And I think that has been an incredibly eye-opening experience for me being in the global organization, is seeing the impact well beyond the US, because I think most companies are very indexed on the US. And we understand US practice well, but I think understanding the impact we can have across the world is also really inspiring, humbling, challenging, and something I think we all have to contend with because it's not the same everywhere. So yes, no, and in between, that's where philosophical lives, so thank you. Dr. Jeremy Cetnar: Yeah. Well, that's a fascinating perspective, the international perspective. Very interesting. Dr. Faris, how about you? Dr. Jason Faris: I completely agree with Lauren. I think on the team question, I definitely feel like we worked on teams in academia as well, whether we're talking about the multidisciplinary groups that are needed to take care of GI cancer patients, which always involves multiple specialties. I think at MGH, in particular, we would tend to go see the patient as a group, which is a bit unusual, to try to get everyone's schedules aligned, to be able to go into the room together. But it really presented an opportunity for the patient and the families to ask questions of us as a group and hear any disagreement that's in the room between the providers right there. There's absolutely a ton of teamwork that goes into taking care of patients. But what you were alluding to, I think, is also right, which is your promotion, your opportunities for advancement are sometimes couched on or developed from accomplishments on the individual side. And I would say more so than is true in industry. I think that's correct as well. I mean, certainly there are multidisciplinary grants that I was a part of, of course, publications that had multiple authors to which I was a contributing author. Sometimes I was first or last author, sometimes I was in the middle, but contributing to the paper. So there was teamwork there, but no question that there's an element of individual accomplishment. How many first- and last-author publications do you have? What's the grant situation look like in terms of ability to supplement the RVUs that you need to generate your clinical…? There's no question that there's an element of that that's not a present to the same degree in an industry role. And I just wanted to speak to the impact side, because I also agree with what Lauren said here. I think the idea and the hope is that in industry, we have an opportunity to potentially affect the lives of many, many, many patients, thousands of patients potentially, with a given cancer type if a new therapy is a homerun and takes off and is approved. That's a huge draw and I think something that motivates all of us is to be a part of something like that. But of course, not every drug, far from it, unfortunately, is going to end up as an approved drug that impacts thousands of patients. So I think it requires some recognition of that fact and patience and continuing to work on multiple projects, and always under the prism of doing the right thing for the patients while those trials are open. And I think that's the key, as well as working on scientifically exciting projects, really proud to say in NIBR that we follow the science. If there's an indication to be explored, based on the science, it may not be the most common indication in cancer, but if the science leads us to that place, that's what we work on. I think that decision making gets tougher, obviously, as you move through the system into a later stage, more commercially informed decision. But I think and certainly on the early phase trials side, that's something that's really exciting. I think on the academic side, taking direct care of patients, you have incredible impact on individual patients, and there's a lot of individual patients. I think you have tremendous opportunity for impact there as well, and your impact can be measured by those that you mentor and teach as well, the committees that you serve on influencing other trials that may be open at your institution. So I would in no way suggest that the impact is less in academia. I don't think that's true at all. I think it's just a different approach. And it is true that if you're lucky enough to work on a program in industry that ends up being an approved drug, you can help thousands of future patients or your team has helped thousands of future patients. That's also true when you're on the academic setting, serving as a PI, contributing safety data and efficacy data, really giving the best information back to the sponsor that you can or maybe you're running your own investigator-initiated study that can change a standard of care down the road. So that's the homerun. That's kind of the Grand Slam of situations that might develop as a medical oncologist on either side of the divide. Dr. Jeremy Cetnar: Thank you. I'd like to shift gears just a little bit and ask you, for people who are deciding for a transition in their career, what are some characteristics or skills or other attributes that you think would make one successful in industry? What are some things that are really, really important to be successful? And that might be different than in an academic situation or not? I'm not sure. And maybe that's another question is, you know, what are some of the things that make people successful in a career in industry? Dr. Abrey? Dr. Lauren Abrey: So I think there are so many things that you can do in industry that depending on what your strength is, I think you have the opportunity to play to that. So again, I think if you are very entrenched in the science, and that is really what makes you want to get out of bed in the morning, being in the early research group, whether it's Novartis, Roche, other companies or small biotech, you can really dig in and spend time thinking and contributing in incredible ways. And if you're the person who is much more interested, perhaps in finding out, what's influencing the patterns of care and why people are using certain drugs or certain treatment paradigms, you could absolutely work on the absolute other end and work in medical affairs and be the person who's out there, who's the critical partner to whether folks at MGH, OHSU, major cancer centers around the world, to figure out how do we bring those two together. And I think the group in the middle typically, like the drug development group that's getting the approval, so running the large Phase 3 studies, that requires people who are in it a little bit for the long haul. Those tend to be large studies. They run over several years, you're constantly looking at the incoming data, and yet you're blind to the results. So you have to be pretty diligent while you're in that space and willing to just buckle down and work hard. But I think there are things for everyone. And I think it's a little bit similar to what I discovered when you went into medicine. Not everybody's going to be a cardiothoracic surgeon. Only a few of us end up in this weird oncology space. But I think it does give you the chance to reinvent yourself and explore a few things. So I wouldn't say you have to have something. I think probably what you should do is talk to a lot of people. I think people make a lot of assumptions about what a change to a career in industry is or means. And you probably don't know what you don't know. So call people like me or Jason or someone who's done it and talk to people, because I think that's probably the best way you can make an informed choice. Dr. Jeremy Cetnar: What do you think, Dr. Faris? Dr. Jason Faris: Can I offer some advice? So are we in this kind of advice section? Dr. Jeremy Cetnar: Absolutely. Please do. Dr. Jason Faris: Yeah. So I would say my advice to oncology trainees would be to keep an open mind and stay flexible. I've got a Wayne Gretzky quote that I'd like to bring into this here, which is 'You miss 100% of the shots that you never take'. And I feel like I've probably taken that flexibility to a bit of an extreme with my career path and transitions. But ultimately, it's really enabled me to experience diverse career opportunities that I might otherwise not have had the chance to really experience. I think sometimes there can be assumptions or negative stereotypes about moves from academia to industry. But my own personal experience, now twice, at NIBR has been overwhelmingly positive. I've learned a tremendous amount from both environments, which I think provides me with a different perspective on design, conduct, and analysis of clinical trials and allows me to bring a patient-centric view into clearer focus in my industry role. I think it's also really critical to recognize that there are significant stressors and positives to each of these career paths. And they're not necessarily one way. I know multiple colleagues who have made a transition from academia to industry. Other colleagues like me who did return to clinical practice in a clinical investigator role or returning from industry to an academic lab, I've seen that happen multiple times, and multiple colleagues, of course, that have transitioned to other industry roles. So regardless of which path someone ultimately pursues, the real critical thing to me is to remember what brought us to medical school in the first place, which is a commitment and focus to patients above all else. I believe this can be achieved in many career options, direct patient care, teaching and mentoring, clinical investigator roles in the academic setting, or in industry by collaborating with academic colleagues and patient groups, focusing on programs that have high potential to advance treatment options for diseases with high unmet medical need. I happen to think GI cancers are the poster child for that, but you know, I'm a bit biased, and designing trials that are as patient-centric as possible. So that's the kind of advice that I would offer to people is not to think of these as mutually exclusive or there's only one way forward or if I make this decision, it's irreversible. I don't think any of those things are true. And I feel like I'm living proof. Dr. Jeremy Cetnar: Dr. Abrey, back to you. Any advice? Dr. Lauren Abrey: I can only agree with Jason, and I know a number of people who've gone in both directions, including some who have been in pharma for quite a long time, and then make a decision to go back to patient care. Sometimes, I'm going to say, like as a final career chapter, but it has been a bit like that, including in countries where it's quite difficult to return to practice, that they need to go back and redo some training. So I think, move forward, do things that make you want to get out of bed in the morning, and that probably will change over the course of your career. But I think don't be afraid to try something because the worst thing that could happen—that's always a good question to ask yourself, right? What is the worst thing that could happen? If it doesn't work out, you can probably make another choice. I also think you should, you know, I already said talk to lots of people. But pay attention to that network that you have and nurture it, cultivate it, because some of those people in your network might become mentors at some point, might become advocates or sponsors at some point. And always, always, always take the opportunity to mentor somebody else, including if you're young, do some reverse mentoring. I have gotten some of my best mentoring from somebody that I agreed to mentor, but he really ended up reverse mentoring me. And he's actually now leading a very small biotech and you could argue has leapfrogged part of my career. And that's a fantastic dialogue that I get to have. So, great fun. We only go around this once. So have some fun while you're doing good things, too. Dr. Jeremy Cetnar: Ain't that the truth? And I'll tell you, this is a small world. It does feel like the more people you talk to, all of a sudden, we all are connected. And so I just want to thank you, Dr. Abrey, Dr. Faris, for your time today, for your perspective, your interesting stories. And to all the listeners, we appreciate you tuning into this episode of the ASCO Education podcast. Dr. Jason Faris: Thank you very much.   Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  

Cancer Stories: The Art of Oncology
My Mother's Last Lesson

Cancer Stories: The Art of Oncology

Play Episode Listen Later Jul 12, 2022 29:51


"My Mother's Last Lesson," by Colt Williams: A resident learns about managing mental illness during cancer treatment.   TRANSCRIPT Narrator: My Mother's Last Lesson, by Colt Williams, MD (10.1200/JCO.21.02382)   In January 2017, my 65-year-old mother was diagnosed with treatable cancer. The problem was that she did not want to live.   Her mental health had declined precipitously after losing my father 8 years before, and her grief proved insurmountable. She had been a functional alcoholic for most of my life, and commonly smoothed over the roughness of a long day with half a bottle of whiskey. Growing up, alcohol had been ubiquitous to the point of banality, yet she was nonetheless able to lead a very successful life. But the silence of my father's absence was deafening, and her few moments of relief were only ever found at the bottom of a bottle. Her life came apart at the seams as she had stopped working, lost contact with most of her friends, and rarely left the house. Then, after years of limitless sorrow, when she was told she had advanced, but treatable squamous cell carcinoma of the tongue, she wanted to allow it to end her life.   Despite a high chance of cure, my mother saw her situation as both cause and justification to end her life. Why pursue a painful and disfiguring treatment to save a life already devoid of light, companionship, or love? She argued that she had already lived a full and rewarding life, and without my father at her side, her existence had become a shell of its former self. Her advanced directive had stated “Do Not Resuscitate” as far back as my father's initial entanglement with cancer, nearly 10 years before. Long before any of these immediate issues arose, she had made it clear that, “When it's my time, it's my time.”   Her treatment team was clear that if she received the standard treatments, her probability of survival was excellent, but that the journey would be grueling. Removing a third of her tongue would likely leave her with permanent speaking and swallowing difficulties. Radiation to her mouth and throat would cause severe inflammation and pain. A temporary feeding tube would pump tasteless, khaki colored goo directly into her stomach to bypass her swollen mouth and throat. She was assured that she would be supported by an interdisciplinary team and given any, and all, measures to ensure her comfort.   She asked what would happen if she chose not to pursue treatment. Her oncologist shifted on his stool, his arms crossing, and his speech slowing. I projected my own thoughts and discomfort onto his change of posture, “Why are you asking him that? It's treatable! Tell her, make her fight!” Her oncologist warned us that her cancer had the potential to slowly rob her of her ability to speak, eat, swallow, and eventually breathe. Even with treatment, there was still a chance she could end up in the same situation if the cancer did not respond or if it came back later. All I could think was “at least we would have tried.”   My mother found the idea of death comforting as she would be released from physical and emotional pain. After our initial visit with her oncologist, however, she became terrified of the symptoms she might experience as she was dying. I too was afraid of what would come. Nightmares of her choking while I watched on powerlessly were frequent over the next few nights. Still, she was not convinced that treatment was what she wanted. I pushed her, begged her to be treated. After a long, emotional, and arduous weighing of her options, I shared with my mother's doctors a collective sigh of relief when she reluctantly agreed to treatment.   Two weeks before her surgery, I went to visit after my medical school classes. We had talked on the phone the night before, and our conversation had left me worried. My father's death was a common topic for us, but her perseveration on the irreparable void in her soul was alarming. I found her stumbling around the house, her shoulder dragging against the wall after she had careened into it. She was a drunk, but never this sloppy—something else was going on. She slid to the floor, eyes half-lidded. “I'm going to go find your dad.” I found the empty bottle of morphine shortly after I had called 911; it was my father's from when he came home on hospice nearly a decade ago. She must have held on to it for all those years, her fire escape from a burning reality.   The morphine was too old and there was too little left in the bottle to kill her, but the message her actions sent was loud and clear. Until examined and cleared by a psychiatrist, she was unsafe to be alone. She had a long history of bipolar disorder, acknowledged but untreated. Her mood would cycle between periods of working late every night to days at a time where she would not leave bed or even shower. There had been stints in the past where she had seen a psychiatrist or tried medication, but they never lasted. She enjoyed being colorful, eccentric, and prone to strong feelings. During the week of her hospitalization, there was no argument that she was unfit to make her own decisions and that her mental health needed serious attention.   After she had returned to an acceptable level of risk to herself, she was discharged on several mood stabilizers and with a follow-up visit with a psychiatrist. She went for a few visits; I suspect more to affirm business as usual rather than out of genuine interest. She quickly stopped going, and her passive suicidality and romanticization of death were ever present. She spoke often of the simplicity and relief of simply ceasing to exist. It has been well established that the risk for suicide is twice as high in patients with cancer compared to the general population, and my mother's history of bipolar disorder and alcoholism further compounded that risk.1 I honestly do not know why there was not a psychiatrist on her care team from the very beginning; her unmanaged bipolar disorder was cause enough to justify comanagement. I deeply regret not having advocated strongly for one from the beginning of her treatment.   As her son and having recently become a new physician, I struggled to know how to help my mother. I tried to delicately toe the line between acting as my mother's advocate and protecting her from herself. In a patient as complicated as my mother, one with extensive comorbid psychiatric illness interspersed with episodes of acute delirium, the patient's history of previous preferences may be quite valuable. In my own fear of losing someone I loved, I lost track of what was truly important to her as a human being. The exigency of her attempted suicide blinded me to the otherwise valid intricacies of her longstanding values regarding her end-of-life care.   Even amid the turmoil of her attempted suicide, the specter of her cancer never strayed far. Ultimately, she resigned herself to treatment, undergoing surgery, completing radiation, and receiving two cycles of chemotherapy. She tried to quit three times, each time her radiation oncologist and I encouraged her to continue. Despite her insistence that life was not worth living, she continued onward, driven more so by the fear of a painful death than by the desire for life itself.   I was acutely aware of her existential angst. At the time, it felt like a festering wound that had been covered merely to spare the eyes of those looking on. I was starting my medicine residency at this point, and my burgeoning understanding of patient care only added to my disquiet. I found her plan of care to be hollow. If she truly did not want to be treated and only wanted to avoid suffering, did treatment have to be all or none? Couldn't her physical suffering be minimized while still respecting her autonomy in her right to choose how she should live and die? More disturbingly, if her desire to forego treatment wasn't sound, why wasn't her mental health being treated more aggressively? I could not put these worries to words, and only with the clarity afforded by time can I now explain what exactly troubled me as new physician, let alone as her son.   The hollowness I felt in her care could not be directed toward her care team, as they provided the standard of care. Her surgeon performed excellently in the operating room, her medical oncologist prescribed appropriate chemotherapy, and her radiation oncologist delivered her radiation with precision. Equally, my mother participated in her care as much as her mental health allowed her to. The health system, however, failed her. It felt as though she received her care piecemeal from each specialist, rather than visiting with members of a unified team. Where there should have been collaboration between oncology and psychiatry, there was fragmentation.   Early integration of psychiatric care would likely have had tremendous impact on the last year of her life. Cancer does not afford us the time to treat our patient's diseases sequentially; her mental health had proven to be as great of a threat to her life as her malignancy. Although distress screening and integrated psychosocial treatment are standards of care set by the Commission on Cancer, access to mental health care is still woefully inadequate in many parts of the United States.2 As oncologists, we will inevitably treat patients with mental illness, addiction, or both. Assessment of and intervention on our patient's mental well-being should be given as much priority during our visits as investigating a new anemia or peripheral neuropathy. When there is not a collaborative care model to fall back on, it is imperative that clinicians strive to ensure that patients receive the resources they need.   Despite it all, despite the arguing, the pleading, the crying, the pain, the suffering, despite completing her therapy as prescribed, her cancer continued to grow and surrounded her airway. She entered home hospice and struggled along for a few more weeks. She called me one morning after another sleepless night, gasping for air, and told me, once again, that she was ready to die.   I had learned to ignore those words, alarm fatigue blunting their emotional impact, but this time there was something different in the way she spoke. She was neither groping for consolation nor lost in the trance-like depths of her grief. Her voice was calm and determined, strength drawn from the finality of her decision. She did not need to fight anymore; the imminence of her death was now inevitable. It was the most peaceful she had ever been in my adult life. Six days later, after she stopped putting food or water into her feeding tube, she finally found the relief she had so long desired.   It has taken these 4 years to realize that my desire for what could be obscured my ability to see what was. More than anything, I wanted to spare her from what I saw as avoidable suffering, but I had also seen an opportunity. She would have needed to be sober for chemo, or risk toxicities above and beyond what was already expected. I let my emotional needs drive how I advised her. I wanted her to be treated because I was too afraid to accept her mortality, and too hopeful that this could be the start of sobriety. In the moment, I told myself that she could not truly want to forsake a future that still held so much potential, that she could not truly be willing to abandon her family. At first, I looked back upon my actions with cold acceptance, telling myself that her untreated mental illness was clouding her judgment. I felt justified in pushing her to continue with treatment in what I saw as my duty to care for her. The steadfastness of my conclusions softened into ambivalence the more I reflected. Through my supposedly benevolent interjection in her life, did I inadvertently cause her more suffering in my attempt to avoid it?   Now, I am no longer certain I would have pushed as hard or for as long as I did, or perhaps have even pushed her at all. Dr. Lidia Schapira: Welcome to JCO's Cancer Stories: The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all of the shows, including this one at podcast.asco.org. I'm your host, Lidia Schapira, Associate Editor for Art of Oncology and a Professor of Medicine at Stanford. My guest today is Dr. Colt Williams, a fellow in medical oncology and ethics at Mayo Clinic. He will be discussing his Art of Oncology article, ‘My Mother's Last Lesson.' Our guest has no disclosures. Colt, welcome to our podcast. Dr. Colt Williams: Dr. Shapiro, thank you so much for having me today. Dr. Lidia Schapira: It is my pleasure. I'd like to start by asking you what you are currently reading, or what you have recently read that you would recommend to our listeners. I suspect that most people who love to write are also avid readers. Am I right? Dr. Colt Williams: You are very right. I actually love science fiction. And I recently picked up Ender's Game - I had never read it despite the media attention it got a few years ago when the movie came out. And boy, it is just as good as I hoped it would be. Dr. Lidia Schapira: That's fantastic. I'm glad you enjoy it. Let's talk a little bit about your essay. It is very, very personal and very moving. The strong message I took from your essay was how important it is to support caregivers, and how important it is to recognize and attend to mental health during cancer treatment. Tell us a little bit about what led you to write and share this very personal moving story. Dr. Colt Williams: My family life growing up was very private. And both when my father initially had cancer in 2009, and then when my mother fell ill in 2017, the culture within my family was very isolating. And I found myself left without much support for myself as a caregiver to my mother. And equally for both my parents, when they were going through cancer treatment had in a way kept them from being able to experience a lot of the help that they needed for both of them. Reflecting back as I grew through my medical training, and became a resident and then a fellow. As I became my mother's primary caregiver, I saw the damage that that had played both for her and for myself. And in reflecting on this, I had always felt that there was something that wasn't quite right with how things had played out with my mother's death. And I really wanted to be able to put to words for my own healing more than anything else, a way to find closure from my experiences. Dr. Lidia Schapira: Let's talk a little bit about the process and the motivation to write as a way to express yourself to achieve some clarity, as you say, to bring closure. How did you get started? And how long did it take you to write this piece? Dr. Colt Williams: Getting started was the hardest part. I initially wrote a very early version of this in medical school when my mother was first diagnosed with cancer as a case report for how we may approach our patients with comorbid mental illness and physical illness. And that first case report changed many numbers of times in the ensuing four years that it took, or five years, actually, until its final form. I started working on it in earnest again, after shelving it about a year ago. It took a solid year of coming back to the piece a few times a month, looking at wording, looking at the way I was writing to really make sure that the message I was wanting to convey was clear because I felt there was so much that I want to explore both of myself, and so much I wanted to share about my experience. But I also knew that I needed to distill down my experience into a few key points that would, one, really resonate with myself in terms of what were the issues that kept me from feeling that I had the closure that I so desired, but two, how can I make this a digestible piece for my audience. And writing has always been something I've enjoyed. I've enjoyed writing poetry. I've enjoyed reading. And for me being able to put pen to paper to help catharsis some of my thoughts has always been very useful for me. Dr. Lidia Schapira: So, did it work? Did this piece give you what you hoped it would give you? Dr. Colt Williams: It did in a bittersweet way. It was very hard sometimes to sit down and really think about some of these harder moments that I shared with my mother and to go back and relive them but in taking the time to very thoughtfully relive what were traumatic experiences for me, I was able to examine them now with the benefit of time, in a way that I couldn't because of my emotional clouding at the time for how intense the emotions were. And so, writing did provide me with a lot of closure. Dr. Lidia Schapira: Sometimes it takes many years to be able to write about something that is emotionally resonant. It's taken me about 20 years to be able to write about a patient that I love dearly who's died, so I totally understand. But what about the other piece that is sharing these very personal thoughts with a broader audience, especially since you're sort of still in training. Dr. Colt Williams: I remember coming away after my mother had died, and we had her cremated and we had finished with our small ceremony for her thinking that the experiences I had had with her mental illness, with her alcoholism, with the attempted suicide, all of this during training were all things that seemed that, at first glance, I may not want to share. This complicates things. I don't want my residency program director to know what's going through or my potential fellowship matches to know the troubles that I've been going through. While I was doing well with things, I felt that there was a lot that not only I could learn, but that could be really helpful for others. Case in point, with how isolating things felt, I felt this need to connect with other people through my experience. And I felt like the conclusions that I had arrived at really coming to terms with the fact that I was and am ambivalent about my actions with how I pushed my mother to receive her care was something that other people could relate to, and that someone else could learn from. And I hoped that I was able to maybe shorten the period from writing, from point A to point B in that process for someone else, through reading about my own experiences. Dr. Lidia Schapira: How has this experience, Colt, informed your work? I can't help but comment on the fact that you're doing a fellowship, not only in oncology but in ethics. Dr. Colt Williams: Extraordinarily informative. I think about my mother often when I see my patients, for better or worse. I can't help but project sometimes with some of my patients, but it gives me a reason to pause and to be patient, whereas maybe some other colleagues may be less tolerant of individuals who are non-adherent with their medication regimen or decided to end their radiation treatments early because of side effects despite the clear risk to their health in doing so. I feel that I can approach patients who can be more complex and may be more nuanced in a way that I can provide them with the grace and with the space that they need to be individuals, even if that does not necessarily line up with what we as their physicians know to be best for their physical health, knowing that not everyone can abide by the restraining needs of cancer treatment. And by extension, with my interest in ethics, there were a lot of things that I saw both in the way that my mother interacted with her physicians, the ways that she was able to push them, the ways that she was able to make them uncomfortable, made me think a lot about how ought we care for patients like this? And who are we as physicians in the roles of our patients' lives? What role are we playing for them? And how should we exert the very clear power that we have and the important role that we have in a way to make sure that we're always acting in our patient's best interests? Dr. Lidia Schapira: That sounds amazing, actually. Can you give me and share with our listeners an example of how your own experience as a caregiver and as a witness to your mother's complicated history, as you talk about her romanticizing deaths, and really being prepared to die, almost from the time she was diagnosed, how that has perhaps impacted your clinical care? Dr. Colt Williams: I can think of a few patients I've seen recently who have come to me after learning that they have metastatic cancer at their time of presentation, very openly discussing forgoing treatment in its entirety, despite there being options proven to not only prolong their overall survival but their quality of life. And I feel that, even within my group, there are some providers that would really, really push strongly for those patients to consider those treatments without taking the time to consider why: why are you approaching your treatment like this? Why are you approaching your disease like this? What is it that makes you think that this is the right way? And I say think not to imply that they think it's wrong or to think that they are thinking wrong, but to truly understand where they're coming from as an individual and as human beings. We all have extraordinarily unique experiences that lead us to become the people that we are. And all those experiences are valid, and simply because my understanding of how I believe I can best take care of you doesn't line up with what your experiences are, does not mean that your goals for your own life are any less valid than what I think you ought to be doing. So, I think at the end of the day, I'm willing to have a conversation more often with my patients. I'm willing to get myself into places that might be both uncomfortable for me as the provider, and uncomfortable with the patient if they're willing to meet me there on common ground, so we can really find what is going to be for them as human beings the best treatment path moving forward - treatment or not. Dr. Lidia Schapira: It's wonderful to hear you and one of the themes that I hear in your approach is that you find medicine not only rewarding but really mission-driven. And part of the mission is to get to know the person who has the disease. I found your essay very powerful because it addressed so many different issues that make caregiving and giving of professional care so complex. One is the idea of a whole person perspective worldview, as you've just explained to us the idea that we want to listen to and help patients tell us what matters to them, and help them live their journey according to their own values and aspirations. But the other is the issue here of the sadness that emerges from your essay. The fact that your mother was ready to accept the sadness and the finality of death. The fact that it was complicated by her lifelong addiction and history of alcoholism, as you say, the deafening silence of your father's absence in her life. And perhaps what she felt she wanted to do for her children whom I am pretty sure you don't say it, but I'm sure she loved dearly. How did you manage to put all of this into the essay? It certainly impressed this reader, but how did you make that decision to include all of these different threads into your narrative? Dr. Colt Williams: It felt dis-genuine to not include them. And how I managed to do it, I think is a mystery to me as well, to be completely honest. The sadness, the pain, so many compromises with her, so many times where I worried about her, so many times where I could think to myself, if only things were a little bit different, if only she could see things and the way that I see things, that was such an integral part of my experience, and through the pain of not being able to have the person that brought you into this world see the value in their own life was really the impetus that led me to the conclusions I'm now able to draw about recognizing her own values and individual. And while I will always intrinsically see her as my mother, and for all the things that a mother means, before she was my mother, she was still her own person. And those beliefs preceded me. And while any child, I think, would want to think that they are the center of their parent's life, sometimes you're not. Dr. Lidia Schapira: In your essay, you share with the readers that you feel that she found her peace before she died. Have you made your peace with her death? Dr. Colt Williams: I think I have now. I struggled with it for a long time. I struggled with whether I did the right thing by encouraging her to seek treatment when she didn't want to. I struggled with whether I should have pushed harder. I fought with myself on both sides of the coin, which way I should have gone playing out the 'ifs'. What if I would have done this? What if I wouldn't have done this? How things could have been different. But in the end, it's the truth that when I spent my last few days with her, it truly was the most peaceful I had ever seen her in my life. That te restlessness that could be felt within her, even before she was ill, was gone. She was finally complete in a way. She, in her mind, had completed her mission. I was in medical school. I was successful. My sister's a lawyer. She's doing well. Her children were grown and taken care of. And she could finally be free of what she felt like were fetters holding her down to a horrible existence. And I think the experience of being able to be present with her and to place myself in her shoes, as best I could, was really enlightening. And I think my last week with her while she was at home dying was the most formative event of my life. Dr. Lidia Schapira: I've never seen you with patients, but I suspect that you're very sensitive to the plight and situation of caregivers. Can you tell me a little bit about that? Dr. Colt Williams: Cancer is a disease that affects not only the patient but the entire family. It takes many people to take care of our patients, from the physicians to the nurses to our pharmacists to our CNAs that are in the hospital, but equally, we see them for an hour, if we're lucky every three weeks, and our patients' family members or their caregivers are with them the other 24 hours a day and the other times, they're always there. And if it wasn't for their caregivers, our patients certainly would not be doing as well as they are. Cancer is not just a disease that affects the organs, but it's also a disease of existential angst. It's a disease that affects our understanding of what it means to be human, of what it means to have a limited time on this earth, to be mortal beings. And those are things that we often as a species avoid encountering until we absolutely have to. As I saw myself, trying to handle this in isolation does not bode well. We are a social people and we rely on our caregivers and our family extraordinarily heavily. And it's just as important to make sure that our patients' families are set up for success if we want our patients to succeed, as it is to make sure that we've dosed our chemotherapy appropriately or provided the appropriate antiemetics before infusion. Dr. Lidia Schapira: Listening to you talk convinces me that you have found your path in onc, and in ethics, and perhaps moral philosophy as well. It's wonderful to hear you reflect. I thank you very much for sending us your work and wish you much success in your career both as an oncologist and ethicist. Dr. Colt Williams: Thank you, Dr. Schapira, for having me. It's been an absolute pleasure to speak with you. Dr. Lidia Schapira: Until next time, thank you for listening to this JCO's Cancer Stories: The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode of JCO's Cancer Stories: The Art of Oncology podcast. This is just one of many of ASCO's podcasts. You can find all of the shows at podcast.asco.org.   The purpose of this podcast is to educate and inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO the mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.    

Lung Cancer Voices
Highlights from ASCO 2022

Lung Cancer Voices

Play Episode Listen Later Jul 12, 2022 37:27


In this episode, Dr. Paul Wheatley-Price speaks to Dr. Andrea Fung of the Kingston Health Sciences Center, and Dr. Shaqil Kassam of the Southlake Regional Health Centre on the key takeaways and highlights at the ASCO 2022 Annual Meeting in Chigago earlier in June.

The Uromigos
Episode 182: ASCO Kidney Cancer Guidelines

The Uromigos

Play Episode Listen Later Jul 11, 2022 32:31


Kim Rathmell describes the highlights of these guidelines.

ASCO Guidelines Podcast Series
Therapy for Stage IV Non-Small Cell Lung Cancer without Driver Alterations: ASCO Living Guideline (Part 1)

ASCO Guidelines Podcast Series

Play Episode Listen Later Jul 11, 2022 13:45


An interview with Dr. Ishmael Jaiyesimi from Beaumont Health Royal Oak and Oakland University William Beaumont School of Medicine in Royal Oak, MI, and Dr. Andrew Robinson from Kingston General Hospital, Queen's University in Ontario, Canada, authors on "Therapy for Stage IV Non-Small Cell Lung Cancer Without Driver Alterations: ASCO Living Guideline." Dr. Jaiyesimi and Dr. Robinson review the latest recommendation updates for first-, second-, and third-line therapy in patients with stage IV NSCLC without driver alterations. Read the full guideline at www.asco.org/thoracic-cancer-guidelines.   TRANSCRIPT Brittany Harvey: Hello and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows including this one at asco.org/podcasts.  My name is Brittany Harvey, and today I'm interviewing Dr. Ishmael Jaiyesimi from Beaumont Health Royal Oak and Oakland University William Beaumont School of Medicine in Royal Oak, Michigan, and Dr. Andrew Robinson from Kingston General Hospital, Queen's University in Ontario, Canada, authors on 'Therapy for Stage IV Non-Small Cell Lung Cancer Without Driver Alterations: ASCO Guideline Update'. Thank you for being here, Dr. Jaiyesimi and Dr. Robinson.  Dr. Ishmael Jaiyesimi: Thank you for inviting me.  Brittany Harvey: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline.  The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology.  Dr. Jaiyesimi, do you have any relevant disclosures that are directly related to this guideline topic?  Dr. Ishmael Jaiyesimi: I do not have any financial disclosures. Thank you.  Brittany Harvey: Thank you. And Dr. Robinson, do you have any relevant disclosures that are directly related to this guideline topic?  Dr: Andrew Robinson: Yes, I do. I have had funding of less than $5,000 from BMS, Merck, and AstraZeneca in the past two years.  Brittany Harvey: Okay. Thank you for those disclosures. So, then let's talk about the content of this guideline update. So, Dr. Jaiyesimi, what prompted this guideline update, and what is the scope of the update?  Dr. Ishmael Jaiyesimi: The purpose of this guideline update is to update the ASCO and Ontario Health guidelines on the systemic treatment of patients with non-driver alteration stage IV non-small cell lung cancer last published in January of 2020.  The update is the result of potentially practice-changing evidence published since the last update. ASCO published the last full clinical practice guideline updates on systemic therapy for patients with stage IV non-small cell lung cancer that included those whose cancer did not have driver alterations in January of 2020.  The scope of evidence for the update guideline is made of ongoing or completed randomized controlled trials for non-driver alterations from 2018 to 2021. These updated algorithms provide recommendations from the ASCO expert panel and emphasized rapid changes in the management of patients with advanced non-small cell lung cancer and the importance of clinical research.  Brittany Harvey: Thank you for that overview, Dr. Jaiyesimi. So, then talking about those changes you just mentioned, I'd like to review the new or changed recommendations for this guideline. So, let's start with for patients with stage IV non-small cell lung cancer without driver alterations, and with high PD-L1 expression and non-squamous cell carcinoma, what are the updated recommendations for first-line therapy?  Dr. Ishmael Jaiyesimi: In addition to 2020 options for patients with high PD-L1, 50% or more expression, non-squamous cell carcinoma, and performance status of zero to one, and absence of targetable oncogenic driver alterations, clinicians may offer a single agent atezolizumab alone, or single agent cemiplimab alone, or a combination of nivolumab and ipilimumab without chemotherapy, or a combination of nivolumab and ipilimumab with two cycles of platinum-based chemotherapy. The number of acceptable options has increased. And each of the recommendations carries a strength of recommendation and quality of evidence with it.  Brittany Harvey: I appreciate you reviewing those options. So, then Dr. Robinson, moving on to the next category of patients addressed in this guideline, for patients with stage IV non-small cell lung cancer without driver alterations and with negative or low positive PD-L1 expression and non-squamous cell carcinoma, what are the updated recommendations for first-line therapy?  Dr. Andrew Robinson: Thank you for that question. So, in addition to the 2020 options for patients with negative, 0%, and low positive PD-L1 expression, with a TPS score of 1 to 49% and I'd add, unknown PD-L1, non-squamous, non-small cell lung cancer and a good performance status, clinicians may offer combination nivolumab and ipilimumab or combination nivolumab and ipilimumab with two cycles of platinum-based chemotherapy.  These are the additional recommendations and this gives an increased number of acceptable options, particularly for patients who cannot or choose not to take cytotoxic chemotherapy.  Brittany Harvey: Understood. Thank you for reviewing those options. So. then the next category of patients this guideline addresses, for patients with stage IV non-small cell lung cancer without driver alterations and with high PD-L1 expression and squamous cell carcinoma, what are those updated recommendations for first-line therapy?  Dr. Andrew Robinson: So, similar to the patients with non-squamous cell carcinoma for patients with stage IV non-small cell lung cancer that is squamous cell and a good performance status of zero to one, clinicians may also offer single agent atezolizumab alone or single agent cemiplimab or combination nivolumab and ipilimumab or combination nivolumab and ipilimumab with two cycles of platinum-based chemotherapy followed by ongoing nivolumab and ipilimumab. So, these are additional recommendations in this group as acceptable options for treatment.  Brittany Harvey: Great thank you for reviewing those options. So, then Dr. Jaiyesimi, what is recommended for patients with stage four non-small cell lung cancer without driver alterations and with negative or low positive PD-L1 expression and squamous cell carcinoma for first-line therapy?  Dr. Ishmael Jaiyesimi: In addition to 2020 recommendations, for patients with negative, TPS 0%, and low positive, with TPS 1% to 49%, PD-L1 expression, squamous cell carcinoma, and performance status of zero to one, clinicians may offer a combination of nivolumab and ipilimumab alone or a combination nivolumab and ipilimumab with two cycles of platinum-based chemotherapy.  Brittany Harvey: Great! So, then we've just reviewed the updates and changes to the first-line therapy recommendations. So, Dr. Jaiyesimi, were there any updates to second- or third-line therapy recommendations for patients with stage IV NSCLC without driver alterations?  Dr. Ishmael Jaiyesimi: For patients with non-squamous cell carcinoma who receive an immune checkpoint inhibitor and chemotherapy as first-line therapy, the clinician may offer paclitaxel plus bevacizumab in the second-line setting.  For the majority of patients with non-squamous cell carcinoma who received chemotherapy with or without bevacizumab and immune checkpoint inhibitor therapy, in either sequence, clinicians should offer the option of single-agent pemetrexed (non squamous cell carcinoma, non-small cell lung cancer), or docetaxel (all histologic types), or weekly paclitaxel plus bevacizumab, (non-squamous cell carcinoma, non-small cell lung cancer) in the third-line setting.  For patients in whom the initial treatment was not a chemoimmunotherapy combination should receive the treatment not given earlier that is platinum doublet chemotherapy (if the initial treatment was monotherapy with an immune checkpoint inhibitor, or dual immune checkpoint inhibitor therapy) and immunotherapy with an approved PD-1 or PD-L1 inhibitor in the second line setting (if the initial treatment was platinum doublet chemotherapy).  Brittany Harvey: Okay, thank you for reviewing those recommendations as well. So, then Dr. Robinson, what is the importance of these recommendation updates for practicing clinicians?  Dr. Andrew Robinson: These updates give an increasing menu of choices for patients and physicians, particularly in the first-line setting. The increased list of acceptable first-line options may help us physicians may run into situations where their preferred first-line option isn't available, or for other reasons shouldn't be given.  Now we recognize that given the increasing variety of options in the first line, it would be really nice if we could have guidelines, that say in this certain patient treatment with nivolumab and ipilimumab is recommended and in that certain patient chemotherapy plus pembrolizumab is recommended, and divide things up that way so that the right patient gets the right treatment.  However, the guideline committee did not feel that this was appropriate at that time as the only comparative data with these different strategies is insufficient, either population-based data or cross trial and network comparisons, that, however well done, do not have a defense against confounders and bias that a randomized study has.  So, the advances in drug development and research in non-small cell lung cancer in the past decade have made available multiple treatment options, particularly for first-line therapy for patients, and to some extent, this has also made the process of decision making in this context challenging for practicing clinicians, especially in the community and for patients and caregivers.  Clinicians need to understand patients' comorbidities as well as other variables that can potentially influence treatment decisions prior to making final therapeutic recommendations for any given patient, and also become comfortable handling a few of these regimens. Each of these are somewhat complex regimens with sometimes subtle and sometimes not-so-subtle differences that require expertise and appropriate treatment and monitoring.  So, with so many options available, it's important that clinicians get familiar with a few of them at least given that all of these regimens are now considered as appropriate standard of care regimens suitable for first-line therapy, it may also help justify physicians, researchers and ethics boards who are participating, designing and overseeing simple clinical trials that pragmatically ask the questions as to what should be used when.  So, physicians should simultaneously become familiar with these guidelines, familiar with different therapies, have expertise in a few of these therapies, and continue to stress cancer clinical trials that may improve outcomes, and also may help us determine which treatment for which patient at which time.  Brittany Harvey: Definitely, that makes sense. Thanks for reviewing these recommendations and also the limitations of the evidence around them. So, finally, Dr. Robinson, how will these guideline recommendations affect patients with stage 4 non-small cell lung cancer without driver alterations?  Dr. Andrew Robinson: Well, there are more options available which should be good but we wish what we meant when we say there are more options for patients, what we meant is that if one option doesn't work that other options are then available.  However, in this case, we mean that there are more options for patients for their initial therapy, particularly including more non-chemotherapy or reduced chemotherapy options.  It's difficult to imagine that many patients and clinicians will now discuss, say 8 options with patients with high PD-L1 lung cancer. Pembrolizumab, cemiplimab, atezolizumab, pembrolizumab with platinum doublet, nivolumab, ipilimumab, nivolumab and ipilimumab chemotherapy, and the majority of patients with high PD-L1 will likely continue to have single-agent PD-1 or PD-L1 inhibitors.  For patients with low PD-L1 lung cancer, the inclusion of nivolumab and ipilimumab without chemotherapy as a potential option may allow some patients to avoid chemotherapy toxicity and trade for other toxicities and choose a different therapy.  Patients who enroll on clinical trials where the comparator arm is any one of these therapies should be comfortable knowing that they are considered acceptable standards. The advancement in non-small cell lung cancer diagnosis and treatment would allow patients with stage IV non-small cell lung cancer without driver mutations who are eligible for immunotherapies with or without chemotherapy, a chance of living longer and the opportunity to participate in ongoing research to further move the ball down the field.  Brittany Harvey: Definitely. And, thank you for reviewing that as well. So, I want to thank you both for all of your work to review the rapid changes in evidence in this field and provide these guideline updates. I want to thank you again for your time today, Dr. Robinson and Dr. Jaiyesimi.  Dr. Ishmael Jaiyesimi: Thank you for having me.  Dr. Andrew Robinson: Thank you. It was a pleasure to be here.  Brittany Harvey: And thank you to all of our listeners for tuning into the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/thoracic-cancer-guidelines. There's a companion guideline update on therapy for stage IV non-small cell lung cancer with driver alterations available there and on the JCO.  You can also find many of our guidelines and interactive resources in the free ASCO guidelines app available on iTunes or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.    The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.     

ASCO Guidelines Podcast Series
Therapy for Stage IV Non-Small Cell Lung Cancer with Driver Alterations: ASCO Living Guideline (Part 2)

ASCO Guidelines Podcast Series

Play Episode Listen Later Jul 11, 2022 11:59


An interview with Dr. Ishmael Jaiyesimi from Beaumont Health Royal Oak and Oakland University William Beaumont School of Medicine in Royal Oak, MI, and Dr. Andrew Robinson from Kingston General Hospital, Queen's University in Ontario, Canada, authors on "Therapy for Stage IV Non-Small Cell Lung Cancer With Driver Alterations: ASCO Living Guideline." Dr. Jaiyesimi and Dr. Robinson review the latest recommendation updates for therapeutic options for patients with stage IV NSCLC with ALK rearrangement or RET rearrangement. They also discuss new agents on the horizon. Read the full guideline at www.asco.org/thoracic-cancer-guidelines.   TRANSCRIPT Brittany Harvey: Hello and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs, covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows including this one at asco.org/podcasts. My name is Brittany Harvey and today I'm interviewing Dr. Ishmael Jaiyesimi from Beaumont Health Royal Oak and Oakland University William Beaumont School of Medicine in Royal Oak, Michigan, and Dr. Andrew Robinson from Kingston General Hospital at Queen's University in Ontario, Canada, authors on 'Therapy for Stage IV Non-small Cell Lung Cancer with Driver Alterations: ASCO Guideline Update'. Thank you for being here, Dr. Jaiyesimi and Dr. Robinson. Dr. Ishmael Jaiyesimi: Thank you. Dr. Andrew Robinson: It's a pleasure to be here. Brittany Harvey: Great! First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Jaiyesimi, do you have any relevant disclosures that are directly related to this guideline? Dr. Ishmael Jaiyesimi: None. Brittany Harvey: Thank you. And, Dr. Robinson, do you have any relevant disclosures that are directly related to this guideline topic? Dr. Andrew Robinson: Yes, I have received funding less than $5,000 from AstraZeneca, Merck, and BMS over the past two years. Brittany Harvey: I appreciate those disclosures. So, then Dr. Jaiyesimi, let's talk about the purpose of this guideline. So, what is the purpose of this guideline update, and what clinical scenarios does this guideline address? Dr. Ishmael Jaiyesimi: The purpose of therapy for stage IV non-small cell lung cancer with driver alterations, is to rapidly update the ASCO and Ontario Health guideline on the systemic treatment of patients with stage IV non-small cell lung cancer, last published in February of 2021. The update is a result of potentially practice-changing evidence published since the last publication in February 2021. The update is based on two clinical trials from 2020 to 2021. The clinical scenario this guideline covers are stage IV non-small cell lung cancer with driver alteration with an ALK gene rearrangement and RET gene rearrangements. Brittany Harvey: Great. So, then let's review those two clinical scenarios that you just mentioned. So, there are a few new recommendations regarding ALK rearrangement. So, what are the recommended first-line options for patients with stage 4 non-small cell lung cancer in an ALK rearrangement? Dr. Ishmael Jaiyesimi: In the previous guideline alectinib or brigatinib were recommended as first-line therapy with a strong recommendation and level of evidence in patients with ALK gene rearrangement, and a performance status of zero to two. In the current update, lorlatinib was cited as the first-line ALK inhibitor that may be offered as an alternative first-line therapy. If alectinib, brigatinib, or lorlatinib are not available, ceritinib or crizotinib should be offered. This is based on the CROWN study that showed alectinib was superior to crizotinib in the first-line setting. Unfortunately, we don't have head-to-head comparative data with alectinib or brigatinib, so we cannot conclude that any one treatment is more effective than the other, and decisions should be made on experience, toxicity, and on. Brittany Harvey: Okay, thank you for describing how a clinician should select between those treatments as well. So, then the second clinical scenario that Dr. Jaiyesimi just mentioned, Dr. Robinson, what is recommended for both first-line and second-line treatment for patients with stage IV non-small cell lung cancer and a RET rearrangement. Dr. Andrew Robinson: Thank you. So, for patients with a RET rearrangement and a good performance status of zero to two and previously untreated non-small cell lung cancer, clinicians may offer selpercatinib or pralsetinib as first-line therapy. Selpercatinib was recommended in the 2020 guidelines and pralsetinib has been added to that. As with other driver mutation recommendations for scenarios where randomized studies against standard non-driver mutation treatments have not been done or completed, these recommendations are with a lower level of evidence and somewhat weaker recommendations, an alternative approach of first-line standard non-driver mutation treatment may also be offered. As a guideline group, we listed this approach of non-driver treatment behind the targeted therapies, because there's a belief that the targeted approach may be superior upfront. But we should also continue to, of course, encourage participation in ongoing trials comparing selpercatinib or pralsetinib to standard first-line non-driver mutation treatment to determine whether our assumptions are correct. For patients with a RET rearrangement who've had previous RET targeted therapy, clinicians may offer treatment as per the non-driver mutation guidelines. And for patients with a RET rearrangement who have had previous chemotherapy, chemoimmunotherapy, clinicians may offer selpercatinib or pralsetinib for them. Brittany Harvey: Okay. And then you've just mentioned some ongoing trials as well. So, that leads to my next question of what ongoing trials and new agents is the panel monitoring for the next guideline iteration? Dr. Andrew Robinson: It's really an exciting time with new agents on trials and I think we can divide it into more driver mutations, more lines of therapy, and more certainty with what we're doing. In terms of driver mutations, there are several phase II and III trials with agents such as sotorasib and adagrasib in KRAS-G12C mutated non-small cell lung cancer, trastuzumab deruxtecan in the DESTINY trials in HER-2 mutated lung cancer, mobicertinib and amivantamab in EGFR, exon 20 insertion lung cancer or HER-2 exon 20 insertion lung cancer, etc. So, looking at more driver mutations is all of those agents plus a number of others that will be coming out over the next couple of years at ASCO. We're also interested in more lines of therapy. So, for patients who progress after standard first-line, say osimertinib with EGFR or after progression on ALK therapies such as lorlatinib. So, we're looking forward to studies such as the CHRYSALIS studies of amivantamab and lazertinib in EGFR mutation-positive patients who have progressed after osimertinib, and other studies that are looking at the increasing treatment options for second-line treatment and third-line treatment. And then we're looking at interest to phase three studies that are comparing targeted agents to docetaxel in the second-line setting such as the sotorasib studies in KRAS-G12C patients and capmatinib and MET exon 14 patients, particularly as many of these patients may do well with non-driver mutated guided first-line treatment. There are phase three trials comparing RET inhibitors to standard first-line chemoimmunotherapy which will also be keenly awaited to see if our, and when I say our, I mean, the ASCO guideline panel and also the thoracic oncology community writ large, our assumption that targeted therapy will be superior to first-line therapy is actually borne out with clinical trial evidence. So, there's plenty of evidence that we're excited to keep our eye on and update as soon as possible, which is more driver mutations, more lines of therapy for patients who have established driver mutations, and more certainty, hopefully, regarding the timing of these various interventions. Brittany Harvey: Definitely, there's a lot going on in this space. So, we'll look forward to the results from these ongoing trials and the panel's review of that evidence, and eventually updated recommendations. So, then Dr. Jaiyesimi, in your view, why is this guideline update important and how will it impact practice? Dr. Ishmael Jaiyesimi: This guideline is important because it emphasizes rapid development in the research and treatment in advanced non-small cell lung cancer and that non-small cell lung cancer are heterogeneous. Clinicians need to identify biomarkers of the molecular pathways, including targetable driver mutations, example: epidermal growth factor receptors, the BRAF, the MET, the KRAS, and etcetera, and fusion rearrangement, example: anaplastic lymphoma kinase, c-ROS oncogene 1, RET, and on that drive malignancy in patients with non-small cell lung cancer, especially in those patients with adenocarcinoma histology and a little or never smoking history regardless of histology. Because of the availability of effective targeted agent for many of these cancers, at minimum, determination of epidermal growth factor receptor mutation status and anaplastic lymphoma kinase rearrangement status before initiating therapy because rapid and sensitive tests are available. An initiation of immunotherapy could increase the toxicity of tyrosine kinase inhibitors later in the patient's course. All this, in my opinion, will impact clinical practice. Furthermore, an opportunity for patients with driver mutation to enrolled in ongoing clinical trials targeting the driver mutations. Brittany Harvey: Yes. You've just mentioned that this is not a one size fits all approach for patients. And so, in your view, Dr. Jaiyesimi, how do these guideline recommendations affect patients living with stage IV non-small cell lung cancer with driver alterations? Dr. Ishmael Jaeysimi: I believe along with my associates the improvement in the treatment of stage IV non-small cell lung cancer brings hope to the patient with driver alteration for a possibility to use targeted therapy and no chemotherapy or immunotherapy upfront to some patients and this may enhance their lives, increase longevity with some tolerable side effects, and better quality of life, and a truly wide range of opportunities for patients to participate in clinical trials. Brittany Harvey: Great! Yes, it seems like the data has come fast, and a lot of new results of recent trials have driven these updated recommendations and we're also looking forward to many of the results from upcoming clinical trials that you both mentioned. So, I want to thank you so much for your work on these guideline updates, and thank you for taking the time to speak with me today, Dr. Jaiyesimi and Dr. Robinson. Dr. Ishmael Jaiyesimi: Thank you, Brittany. Dr. Andrew Robsinson: It was a pleasure to be here and I hope that this was educational. Brittany Harvey: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the full guideline go to www.asco.org/thoracic-cancer-guidelines. There's a companion guideline update on therapy for stage IV non-small cell lung cancer without driver alterations available there and on the JCO. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app available on iTunes or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO the mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.  

The ASCO Post Podcast
ASCO 2022: Plenary Presentation in Colorectal Cancer

The ASCO Post Podcast

Play Episode Listen Later Jul 8, 2022 13:11


In this episode, we continue to highlight research presented at the 2022 ASCO Annual Meeting. We'll first hear a discussion between two researchers on Plenary Abstract LBA1, which may establish a standard first-line combination regimen for patients with RAS wild-type and left-sided metastatic colorectal cancer. Then, we'll hear about a study that highlighted the need to increase participation in clinical trials amongst Black women with metastatic breast cancer. To listen to more podcasts from ASCO, visit asco.org/podcasts.

OncLive® On Air
S7 Ep12: Research Reflections: Tarantino Talks Through the Implications of ASCO 2022 Data in Breast Cancer

OncLive® On Air

Play Episode Listen Later Jul 7, 2022 22:48


Dr Tarantino discusses practice-changing findings in breast cancer and emphasizes the ways in which positive study data can improve the breast cancer treatment paradigm going forward.

CCO Oncology Podcast
New Evidence With BTK Inhibitor Therapy in CLL and MCL From ASCO 2022

CCO Oncology Podcast

Play Episode Listen Later Jul 6, 2022 32:16


In this episode, Brad S. Kahl, MD, and Anthony Mato, MD, MSCE, discuss their choices of 3 recent important trials presented at ASCO 2022 evaluating the use of BTK inhibitors in chronic lymphocytic leukemia (CLL) and mantle cell lymphoma (MCL). The discussion will include analyses of: The SHINE trial evaluating the addition of ibrutinib to bendamustine/rituximab followed by rituximab maintenance in the first-line setting for older patients with MCL3-year follow-up analysis from the CAPTIVATE fixed-duration cohort of first-line ibrutinib plus venetoclax for CLL/small lymphocytic lymphomaPhase I/II study of zilovertamab, an anti-ROR1 antibody, plus ibrutinib in MCL or CLLPresenters:Brad S. Kahl, MDProfessor of MedicineDepartment of Medical OncologyWashington University School of MedicineSt Louis, Missouri Anthony Mato, MD, MSCEAssociate ProfessorDivision of LeukemiaMemorial Sloan Kettering Cancer CenterNew York, New YorkSee full program:https://bit.ly/3OQ6634

Cancer Stories: The Art of Oncology
To the Cadaver With the Port

Cancer Stories: The Art of Oncology

Play Episode Listen Later Jul 5, 2022 22:24


"To the Cadaver With the Port," by Kendahl Servino: A medical student begins school in the midst of a pandemic, but also, in the middle of cancer treatment.   TRANSCRIPT Narrator: “To the Cadaver with the Port” by Kendahl Servino, B.S. (10.1200/JCO.21.01979) It was easy to spot the cadaver's port implanted in her chest. The small, triangular object stood out against the pallor of her skin, preserved in the same manner as the rest of the bodies in the anatomy laboratory. As first-year medical students, we met our very first patients here. A quiet veneration was interlaced in the air amid the formaldehyde, and it clung to us the first day we stepped into the anatomy laboratory. It was easy to spot the cadaver's port implanted in her chest. The small, triangular object stood out against the pallor of her skin, preserved in the same manner as the rest of the bodies in the anatomy laboratory. As first-year medical students, we met our very first patients here. A quiet veneration was interlaced in the air amid the formaldehyde, and it clung to us the first day we stepped in the anatomy laboratory; we recognized the privilege given to us to learn about life and death through the human body in such a personal manner. Yet amid the reverence, I mourned this cadaver in particular, because the small port was a device used to administer chemotherapy. Easily overlooked by one unfamiliar with its purpose, it was a telling sign of cancer. It was the same port that I had in my own chest. In the midst of a busy anatomy laboratory session that day, I was immediately taken back to a different day 9 months ago. During the winter break of my last year of college, I drove myself to the hospital for a seemingly innocuous visit and walked out with a cancer diagnosis, unable to fathom what had just happened. Graduating college, celebrating with friends, and starting my career in medical school had been the milestones of my foreseeable future; finishing chemotherapy, ringing the bell at the end of treatment—a monumental moment for many patients—and surviving cancer had not been among them. I never expected to grapple with my mortality at 20 years old. As I stared at the cadaver's port, I wondered: was she with anyone when she was told she had cancer, or had she been alone, like me? Had she been devastated upon learning of her diagnosis, overcome by shock as I had? What kind of care did she receive thereafter? Did she have faith in herself? Had she felt hurt, searching in vain for an explanation of why she had been dealt such desolate cards? Did she feel betrayed by her own body, as I had? Moments of my own experience flooded back as I stood by her lifeless side. Looking at her face, still as though she were asleep, I wondered if she asked herself the same questions that I could never find the answers to myself. Even if every other aspect of our life stories were different, I knew at the very least that this cadaver and I shared the burden of a shattering diagnosis. I suspected that we shared the weight of the concomitant struggles that quickly follow the words, “You have cancer.” Having spent the past year receiving chemotherapy and radiation, losing my hair, and most importantly, struggling with the overlooked, psychologic side effects of cancer, never in my life had I felt so lost. I wondered whether the cadaver with the port had felt this way too.   At times, it has been hard for me to heal while in the medical school, an environment that often reminds me, although unintentionally, of the trauma that cancer precipitated. When I observe the skillful hands of the attending physician as she instructs how to conduct a proper breast examination, I am pulled back to the memory of stumbling out of the women's health clinic in a trance, numbed by what I had just been told. During lectures taught by brilliant professors on chemotherapeutic agents, I cannot help but recall the memory of sitting in the infusion center watching those very drugs dangling from the intravenous pole drip inside me. During a charged class debate on the efficacy of self-breast examinations, I struggle to sequester the unsettling feeling that arises in my stomach as I am prompted to revisit the emotional burdens of what I endured. And soon, when my classmates and I learn how to deliver hard news to patients, such as a diagnosis of cancer, I will be reminded of what it felt like sitting in my patient's chair. As I stand at the intersection between the medical student and the patient with cancer, I am learning that studying a disease, understanding its pathophysiology and mechanisms behind the indicated treatment, is entirely different from being on the receiving end of those medications or being the recipient of the diagnosis. Because of my dual identity, I am slowly understanding what it fully means to empathize with patients' situations. As I felt connected to the cadaver, I realized so too would I see myself in my future patients' struggles. Despite the burdens that I am currently working through, my experience with cancer has provided me something to offer to others, something that has, and will continue, to connect me to others. For the first time since starting the medical school, I am beginning to see a future not clouded by trauma, but instead filled with the potential for impactful connections and beautiful moments. If nothing else, I write this as a thank you to the cadaver with the port. Thank you for teaching me about life through your death, and for reminding me that there is so much of mine left to live. Thank you for reminding me that there have been others who have shared my struggles and that our pain does not exist in a vacuum. Healing, I realize, is not linear. But the power of shared experiences can help heal wounds, including those that lie deep within us. These moments are found not in textbooks or in lectures, but instead between two individuals when all other differences are cast aside. And while my patients may thank me one day for changing their lives, I will have to thank them for changing mine. Dr. Lidia Schapira: Welcome to JCO's Cancer Stories: The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all of the shows, including this one at podcast.asco.org. I'm Lidia Schapira, professor of Medicine at Stanford, associate editor for JCOs Art of Oncology, and your host for this program. With me today is Kendahl Servino. Kendahl is a second-year student at the Reno School of Medicine and the author of, ‘To the Cadaver with the Port'. Our guest has no disclosures. Welcome to the program, Kendahl. Kendahl Servino: Thank you, Dr. Schapira. It's great to be here today. Dr. Lidia Schapira: So, before we start, I like to ask our authors to tell me a little bit about their process for writing, and first of all, what they enjoy reading. So, what would I find on your virtual night table today? Kendahl Servino: I've always been a writer. When I think about my childhood, it's comprised a lot about many trips to the public library. My parents encouraged my brothers and me to read from a young age and I have just a plethora of memories of going to the library after school. And on summer vacations, we would just spend our free time there. Books were just a great way to experience other lives vicariously and to really see different perspectives. My love for reading translated into my own interest for writing. As a child, I have memories as early as kindergarten of me writing. I would take those standard 8 by 10 computer pieces of paper, I would take a stack of them, I would fold it in half. And I would staple it along its spine. And I'd create essentially a little book. I think the first book that I ever wrote was in kindergarten, and it was about this talking rose on a farm. And there was this whole rivalry and it was very vivid in the imagination of a six-year-old. But writing has always just been a part of my life, and especially coping with cancer became a lot more meaningful and impactful to my life. Dr. Lidia Schapira: So, writers are usually readers as well. So, I'll go back to my initial question. Also, what books are you reading now? Or what book would you recommend to our listeners that you've read in the last year or so if you've had time to read as a medical student? Kendahl Servino: Time is definitely limited. But currently, I'm reading a book called, A Little Life, by Hanya Yanagihara. I'm not sure if I pronounced your name correctly. And I'm not sure if you've heard of this book, either. It's a pretty big book, I think it's 800 or so pages. But it's about these four men who met in college, and they are currently living in New York and they're struggling with the transition into adulthood. They're dealing with a lot of issues. It's not for the faint of heart, I would say because there are a lot of trigger warnings in this book. They deal with a lot of issues such as self-harm, eating disorders, and mental health. There's all a lot of issues that they cover, but you get really close and connected with the characters and you feel a sense of bond with them by the end of the story. I don't want to give too much away about these characters' storylines, but it's a very impactful book so far that I would recommend. Dr. Lidia Schapira: So, it's interesting to hear you talk about this book that you admire, and that touched you because your essay had the same effect on the readers and certainly on me. It starts with this amazing line. I want you to tell us a little bit about that experience that you had as a very young cancer survivor, choosing to attend med school walking into the anatomy lab, and then seeing this device that you recognize on your cadaver's chest wall as a port, and that amazing way that you phrase the fact that you immediately felt this connection to this cadaver, bring us to that day. Kendahl Servino: Yeah. So, I'll start with a little background. So, starting medical school, I was in the middle of cancer treatment. Actually, right before I started medical school, I just finished radiation therapy. And within a couple of days after finishing and leaving my radiation oncologist's clinic, I moved to Reno, I was living in Las Vegas originally. So, all of this was still pretty fresh. And, admittedly, I mean, it still is right now. It's been about a year since I finished treatment. But the height of treatment was when I started medical school. And so, everything was still really heightened emotions at the time. And upon seeing that cadaver with the port, it was really surprising to me, because even though I had finished chemotherapy myself, and I had been about three or four months out from finishing chemotherapy, my hair was finally starting to grow back at that time, I think seeing that cadaver with a port showed me that cancer is never really over. That's something that I've been learning. And so, you think about ringing the bell. For those who aren't familiar, there's this bell that's often in many cancer clinics. It's this giant bell on the wall that you get to ring when you finish treatment. It's a really impactful moment, for not only the patient who's ringing the bell, but also everyone else in the clinic who can hear and understand the struggle of what the patient went through, and it's a collective celebration and something really special for cancer patients. So, you think about that as being kind of the end all to finishing cancer treatment. But what I've been learning since finishing treatment on my own and since being in medical school is that cancer treatment or cancer itself, and any other monumental diagnosis like this does not really have a finite ending. It'll always carry and stay with you, for better or for worse. I think that reminder of seeing the port, and seeing that connection reminded me that I will always have this part of me, this has changed me even a couple of months out from chemotherapy, or even a decade into my own future practice as a physician. And this will be an experience that will always stay with me and hopefully connect me more with patients in the future as I felt connected to the cadaver. Dr. Lidia Schapira: In your essay, you reflect on the psychological side and the psychological suffering that accompanies that cancer journey and the diagnosis and you also talk a lot about connection as something that you find very important in thinking about your future as a physician. Can you tell us a little bit about the emotional process and the healing that's taking place now even? Also, if you can, can you reflect a little bit on sort of your dual identity as a cancer survivor now and medical student, and whether or not it's really problematic for you? Kendahl Servino: Some of the psychological effects were a lot more monumental, I would say a year ago from now when I started medical school. Medical school is a very challenging transition for anyone undertaking this experience. And I definitely had struggles adjusting to medical school, but I think as a cancer patient, on top of that, I faced a lot of unique challenges. I think that had a lot of impact on mental health. For example, I was wearing a wig at the time. I was bald. So, that was really hard on top of moving to medical school. And, of course, in the midst of a pandemic, on top of everything else. Things were hard for everyone at the time but being a cancer patient posed some unique challenges for me, amongst my classmates. And so, you asked about the dual identity between cancer patient and medical student, and you asked about whether it's problematic. And admittedly, at the beginning of medical school, I think I really struggled with learning about, say, the chemotherapeutic agents that we'd receive lectures on, learning about how to conduct a proper breast exam. And those were very triggering for me, having just experienced that so recently, and so sometimes I thought that the trauma that I was reminded of so frequently, but unintentionally, in medical school was a lot for me, and something that I have been working through and I'm thankful to say now that a year later, I'm no longer as triggered by these moments in school, although they still come and go. But I think seeing the flip side of what it is like from the patient's point of view and the provider's point of view is really insightful because as medical students, we're learning to become providers and our role is to offer care to our future patients. And as a cancer patient myself, I've had unique insight into what it's like sitting in the patient's chair, being a patient with more medical needs than most. So, in some ways that dual identity has proffered really great insight into what my patients might be experiencing and feeling. But on the other hand, it also precipitates a lot of emotion, sometimes strongly that I am not ready to face again, or would want to be reminded of. Dr. Lidia Schapira: As you speak, Kendahl, it occurs to me that you probably need to sort of make a decision about how much you want to share about your personal circumstances, very often with your professors, with your classmates, even with your patients. How do you manage that? Kendahl Servino: Truthfully, I'm still trying to figure out the balance too, between oversharing and wanting to share, because I think that I have a lot to offer, the way that anyone who has overcome challenges can share something with others. As far as my future practice, and you mentioned future patients, I think that's something that I would like to connect with my future patients about in a way that is understanding of their own circumstances and whatever it is that my patients are going through with the intention of letting them know that I can understand to an extent of what they're experiencing, what they're going through, and I'd hope to convey that I will do all that I can, in my own future practice to help them and to help them heal. Dr. Lidia Schapira: Back to you, has your medical school, and do your professors and classmates support you in the way that you need to be supported? Are they there for you on a bad day? Kendahl Servino: I would say so. I don't have too many bad days, thankfully, as I did before medical school. I would say that the semester before medical school, which was the semester that I was in chemotherapy, I think that was my absolute lowest. And so, being in medical school, I haven't experienced that, thankfully, but I do have my support system here. I'm really thankful for them. I have been pretty public about my experience. Also, I created a blog a couple of years ago that I started out in college to convey my experiences as a college student and going through the formative time that college brings. But during cancer treatment, I also used that as a coping mechanism. Going back to writing has been part of my roots. I blogged a lot about my experiences. And now on social media, I post about some of my experiences. I try not to post just about the accomplishments, I also like to share, to an extent, the challenges also and the hard times, because I'd like to stay true to the authentic experience that cancer was and it wasn't just ringing the bell. It wasn't just accomplishing these milestones. It was also about my lowest times and the times that I wasn't sure I'd get through it. And so, I like to share all of that, and I try to be as authentic and genuine about my experience. Dr. Lidia Schapira: Well, I hope the process of writing this essay that you sent to JCO was helpful and was therapeutic for you as well. And coming back to your writing, which is beautiful, it's crisp, it's clearly very intentional, what is the message for the readers of JCO? Kendahl Servino: Thank you! I would say that cancer was, inarguably, the most challenging thing I've ever experienced in my life, bar none. And I would never want to go through something like that again and I would never wish that upon anyone else either. But I do believe now that it will help me in becoming the best doctor that I can be one day in my future practice. I think that's the most that I can ask for from an experience like cancer and the most that I hope to bring out of it is the impact that I can give to my future patients. Dr. Lidia Schapira: Beautifully said. So, I'm just curious, do you know what path you'll follow in medicine? Do you have an idea of what kind of doctor you want to be? I know a good one and one that connects with her patients, but do you have any idea of where you're headed? Kendahl Servino: Yeah, I currently do have interests in something oncology-related. I'm not sure at the moment whether that will be the medicinal route or the surgical route. I got to know both sides of the spectrum through my oncologist, but I also got to know my plastic surgeon who was on my team as well. And I have interests on both sides of the spectrum. But I think something related to oncology would be really fulfilling and impactful to my career and hopefully be able to change the lives of patients going through something that I've experienced so personally. Dr. Lidia Schapira: Well, hold on to that feeling. Thank you so much for writing. I wish you good health. And I hope you do join the global cancer tribe in some capacity. It was lovely to get to chat with you, Kendahl, and to read and reread and reread your essay. Thank you very much! Kendahl Servino: Thank you so much. It was great being here and I appreciate you inviting me. Dr. Lidia Schapira: Until next time, thank you for listening to this JCO's Cancer Stories: The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode of JCO's Cancer Stories: The Art of Oncology Podcast. This is just one of many of ASCO's podcasts. You can find all of the shows at podcast.asco.org.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.    

Healthcare Unfiltered
Pharmacovigilance and Adherence to Oral Oncolytics

Healthcare Unfiltered

Play Episode Listen Later Jul 5, 2022 55:13


Joining Chadi on today's show is Donald Harvey, PharmD, BCOP, FCCP, FHOPA, Winship Cancer Institute of Emory University. Dr. Harvey shares available career paths and how the pharmacist role has evolved over the years, how pharmacists continue to stay involved with patients after discharge, strategies he uses to help cancer patients adhere to oral oncolytics, and his “Call to Action” to improve such adherence – as co-planned by the FDA and ASCO and published in Journal of Clinical Oncology. The discussion is very detailed and enlightening; you won't want to miss it! View Dr. Harvey's publication “Call to Action for Improving Oral Anticancer Agent Adherence.” https://ascopubs.org/doi/10.1200/JCO.21.02529 Check out Chadi's website for all Healthcare Unfiltered episodes and other content. www.chadinabhan.com/ Watch all Healthcare Unfiltered episodes on Youtube. www.youtube.com/channel/UCjiJPTpIJdIiukcq0UaMFsA

The ASCO Post Podcast
ASCO 2022: Research in Multiple Myeloma and Breast Cancer

The ASCO Post Podcast

Play Episode Listen Later Jul 1, 2022 12:49


In this episode, we'll hear about results from the phase III DETERMINATION trial in multiple myeloma, and a study that sought to determine when radiotherapy may be avoided after breast-conserving surgery.To listen to more podcasts from ASCO, visit asco.org/podcasts.

Cancer.Net Podcasts
2022 Research Round Up: Prostate, Testicular, Bladder, and Kidney Cancer

Cancer.Net Podcasts

Play Episode Listen Later Jun 30, 2022 49:09


ASCO: You're listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests' statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In the Research Round Up series, members of the Cancer.Net Editorial Board discuss the most exciting and practice-changing research in their field and explain what it means for people with cancer. In today's episode, 4 Cancer.Net Specialty Editors discuss new research in prostate, bladder, kidney, and testicular cancers presented at the 2022 Genitourinary Cancers Symposium and 2022 ASCO Annual Meeting. This episode has been adapted from the recording of a live Cancer.Net webinar held June 15th, 2022, led by Dr. Neeraj Agarwal, Dr. Timothy Gilligan, Dr. Petros Grivas, and Dr. Tian Zhang. Dr. Agarwal directs the Genitourinary Oncology Program at the Huntsman Cancer Institute at the University of Utah. Dr. Gilligan is an Associate Professor and Medical Oncologist at the Cleveland Clinic Taussig (TOSS-ig) Cancer Center. Dr. Grivas is the clinical director of the Genitourinary Cancers Program at University of Washington Medicine. He is also an associate member of the clinical research division at the Fred Hutchinson Cancer Research Center. Dr. Zhang is an Associate Professor of Internal Medicine at UT Southwestern Medical Center and a medical oncologist at the Harold C. Simmons Comprehensive Cancer Center. Full disclosures for Dr. Agarwal, Dr. Gilligan, Dr. Grivas, and Dr. Zhang are available at Cancer.Net. Greg Guthrie: Good afternoon, everyone. I'm Greg Guthrie, and I'm a member of the Cancer.Net content team. I'll be your host for today's Research Round Up webinar focusing on cancers of the genitourinary tract. Cancer.Net is the patient information website of the American Society of Clinical Oncology, known as ASCO. So today, we'll be addressing research from 2 2022 scientific meetings, the ASCO Annual Meeting held in Chicago in June and the Genitourinary Cancers Symposium held in San Francisco in February. Our participants today are all Specialty Editors of the Cancer.Net Editorial Board, and they are Dr. Neeraj Agarwal of the Huntsman Cancer Institute in University of Utah, Dr. Timothy Gilligan of the Cleveland Clinic Taussig Cancer Center, Dr. Petros Grivas of the Fred Hutchinson Cancer Research Center and University of Washington, and Dr. Tian Zhang of the University of Texas Southwestern Medical Center. Thank you, everyone, for joining us today. So starting us off today is Dr. Agarwal who will be talking about research in prostate cancer. Go ahead, Dr. Agarwal. Dr. Agarwal: Hi. Thank you, Greg. So I'd like to start with 2 studies. They both are in prostate cancer which will be followed by my colleagues presenting studies in other cancers in bladder cancer and kidney cancer. So I'll start with this abstract, which was highly discussed by the doctors at the ASCO Annual Meeting a few weeks ago, and it has a lot of relevance in our practice. So this is abstract #5000 presented by Dr. Michael Hofman, and this was the update on a clinical trial which compared lutetium PSMA-617, or lutetium PSMA, to put it simply, with cabazitaxel in patients with metastatic castration-resistant prostate cancer who had disease progression after receiving docetaxel chemotherapy. So, who were the patients who were enrolled on the study? These patients had, as I said, metastatic castration-resistant prostate cancer, who had disease progression after docetaxel chemotherapy, and who had to have high PSMA-expressing prostate cancer. And the way they assessed the presence of high PSMA expression was by using a specialized kind of PET scan known as Gallium 68 PSMA-11 PET scan. In addition, they made sure that these patients do not have another type of prostate cancer, also call it dedifferentiated prostate cancer, by making sure that those patients did not have a traditional PET scan-positive disease. So this was a highly selected patient population who were expressing PSMA on their prostate cancer. Prior to this presentation, the earlier presentation had shown that lutetium PSMA was superior to cabazitaxel as far as progression-free survival is concerned and also was associated with lower incidence of grade 3 or 4 side effects. In this update, after a longer follow-up of 3 years, Dr. Hofman and Dr. Davis, who is a senior author, they presented the data on overall survival, which was a secondary analysis, and overall survival was similar with cabazitaxel as well as lutetium PSMA in the range of 19 months. We did not see any new safety signal. So, what does it mean for us? What does this mean for our patients? My key takeaway message here is, lutetium PSMA is a suitable option for men with metastatic castrate-resistant prostate cancer who are expressing high PSMA on their prostate cancer after they had sustained disease progression after docetaxel. However, cabazitaxel is also a valid option in this setting. I would like to add my own view in addition to this because lutetium PSMA was better tolerated and was also associated with better progression-free survival. In my patients who are progressing on docetaxel chemotherapy, I would like to use lutetium PSMA first followed by cabazitaxel chemotherapy. So that would be my key takeaway from this abstract. Now we can move to the next abstract. This was also an update, a much longer update, on ENZAMET trial. If you recall, ENZAMET trial was one of those trials which established that deeper androgen blockade, or deeper androgen signaling inhibitors such as enzalutamide, apalutamide, or abiraterone, these trials were conducted in 2015 onwards, and all these trials showed that upfront using deeper androgen signaling inhibitors at the time of metastatic hormone-sensitive prostate cancer onset improved survival. So ENZAMET trial used enzalutamide, and it showed in the first analysis, which was presented by Dr. Davis and Dr. Sweeney in the 2019 ASCO Meeting Plenary session, that adding enzalutamide to androgen-deprivation therapy in patients with metastatic hormone-sensitive prostate cancer significantly improved survival. In this longer follow-up of 68 months, so we are talking about almost 6 years of follow-up, now, these investigators from ENZAMET trial, as presented by Dr. Davis, showed that the combination of enzalutamide with androgen deprivation therapy or testosterone suppression therapy continues to significantly improve survival in patients with newly diagnosed hormone-sensitive prostate cancer or metastatic prostate cancer. One interesting part of this unique aspect of this trial was that patients were allowed to receive docetaxel chemotherapy concurrently to the protocol treatment. And in this trial, 45% patients actually receive docetaxel chemotherapy. So 503 patients exactly out of 1,000-plus patients. So if you look at the subgroup analysis of those patients who received docetaxel chemotherapy, enzalutamide does not seem to benefit those patients from the overall survival perspective. So on the face of it, it looks like enzalutamide is not helping those patients who are receiving docetaxel concurrently. But there are some caveats with that kind of subgroup analysis. The first one is this is not a randomized assignment of docetaxel chemotherapy. Patients were determined to have docetaxel chemotherapy after discussion with their respective oncologist. This was not a prespecified analysis that so many patients with docetaxel will receive enzalutamide. Also, this was not a randomized assignment of docetaxel. And third, that I don't think this trial had enough power to look for that subgroup analysis. So my take on this trial is that updated results from this trial, almost 6 years of follow-up now show that enzalutamide continues to improve overall survival with a 30% reduction in risk of death in patients with metastatic castration-sensitive or hormone-sensitive prostate cancer. Furthermore, the effect of enzalutamide, in my view, on overall survival is independent of the receipt of docetaxel. If you look at the whole trial population for which the trial was covered for, enzalutamide improved survival for all patients. And based on these results, I feel more confident in saying that upfront intensification of treatment with deeper androgen inhibition remains a standard of care for our patients with metastatic hormone-sensitive prostate cancer and should be offered to all eligible patients with this condition. With that, I would like to wrap up the prostate cancer abstracts. Thank you very much. Greg Guthrie: And thank you, Dr. Agarwal. Next up, we will have Dr. Gilligan, who is going to be discussing testicular cancer. Dr. Gilligan: Thank you very much. So I have 2 studies I want to talk about and then just give a headline of some interesting things that I think are kind of coming down the road. Both of these abstracts have to do with improvement over time in specific patient populations we used to worry about. I'm not saying we don't worry about them anymore, but things are looking better now than they had 1 or 2 decades ago. So the first topic addresses late relapses in testicular cancer. And historically, we have been concerned that these patients did worse and had worse outcomes. And late relapse could variously be described as after 2 years or after 5 years. In the current study, they defined late relapse as being after 2 years and very late relapse as being after 5 years. And what was special about the study was that it captured the entire population of patients with testis cancer in Norway and Sweden so that it wasn't based on a center of excellence that gets selective referrals. It was actually a population-based study. And the key conclusion of the study was one I found, once again, that late relapses are rare. So for stage I patients, 2% of patients will relapse after 2 years, 1% after 5 years, and 0.5%, so 5 out of 1,000 patients, after 10 years. So if you're 2 years out, the likelihood of a relapse is quite low. And if you're 5 years out, it's half of that. In patients with metastatic disease, similarly, 3.6% relapse after 2 years, 1.6% after 5, and 0.8% after 10 years. And what was interesting to me was that if you looked at the more recent patients who were diagnosed after 1995 - I know that doesn't sound very recent, but they had even earlier patients also in the study - the very late relapse rate almost resolved and went away. It went from 2.2% all the way down to 0.8%. So I think with modern imaging, modern care patterns, we're seeing less of this than we used to. But overall, patients were doing better even if they do relapse late. One thing that was interesting in the study to me also was for stage I disease, we typically recommend surveillance rather than active treatment. So active treatment with non-seminomas would be a retroperitoneal lymph node dissection or more surgery or chemotherapy. With seminoma, it would usually be chemotherapy or radiation, although surgery is being investigated there now. And they did find that in men who chose surveillance, which we still recommend, the late relapse rate was a little bit higher, but it was still affecting a small percent of patients. So the relapse rate beyond 2 years was 4% rather than 1%, but out of 4,000 patients, there were only 3 deaths from late relapse. So this isn't changing the recommendation for surveillance, but it is an alert that patients who are on surveillance for stage I disease have a slightly higher risk of late relapse and that may affect how we follow them and specifically how long we follow them. One of the things that was interesting in the study is in the United States, we often stop scans at 5 years, but in the SWENOTECA countries, they continue scans all the way out to 10 years. I don't know that U.S. guidelines are going to change, but it was a provocative finding. The key thing, as I alluded to at the beginning, was that 61% of patients with late relapse were alive 10 years later, and while we would like that number to be higher, it used to be around 50% in older studies. So it's a significant improvement from where we were before. A particularly interesting thing to me was that patients relapsing 2 to 5 years out actually had the best prognosis. Patients who relapsed in years 1 to 2 had a worse prognosis and patients relapsing after 5 years had a worse prognosis, whereas the patients relapsing 2 to 5 years had a better prognosis. In the end, I think what this means for us is that patients are doing better. It's not going to really change our treatment patterns, but it's reassuring that we shouldn't be pessimistic about late relapses, and we still have a solid chance of curing them. So again, bottom line, most men with late relapse is cured and late relapse is less common now than it was earlier, particularly in non-seminomas. Let's go to the next study. So this is a different group of patients who had a particularly ominous prognosis historically and still we have a lot of room for improvement. These are patients with non-seminomas that start in the mediastinum. So in the chest, under the breastbone, under the sternum typically. And patients are treated aggressively upfront, they are considered poor risk at the initial time of diagnosis, and they're treated aggressively at the time with 4 cycles of BEP or 4 cycles of VIP chemotherapy. And then they go for surgery to remove any residual disease. And the hope is they're cured at that point because historically, if there was a relapse after chemotherapy and surgery, it was almost impossible to cure them. Indiana University published their results using high-dose chemotherapy in this population, and they reported that 30% of men who were treated with high-dose chemotherapy had no evidence of cancer after 2 years, and 35% were still alive. Obviously, we need longer follow-up, but most of the relapses you're going to see are going to be in the first 2 years. So while again, there is significant room for improvement here, this indicates that high-dose chemotherapy is a good option, and that has been a question. So this is reassuring in that regard. But it is a good option for men with relapsed mediastinal non-seminomas of the germ cell tumors. So there's hope there where in the past, this has felt a little bit helpless. The thing I wanted to also highlight was that there are 3 things I think are going to be interesting to keep an eye on over the next year. One is the use of surgery for early-stage seminomas. There are a number of papers out about that. I still think this is an investigational approach, and so I didn't want to go into great detail about it, but it is looking like that RPLND, or retroperitoneal lymph node dissection, will likely or may be an option for stage I and stage II seminoma in the future. We are getting more evidence for that. It's not quite as promising as we had hoped until there's more data that's needed, but it's looking like that will become an option. So for men with early-stage seminoma, at least raising the question whether surgery is an alternative to chemotherapy or radiation, is an important discussion to have with your oncologist. Secondly, MRI rather than CT scans for surveillance. So to keep an eye on men who have been treated or men who are just stage I and are being followed and typically come in routinely for CT scans, which expose people to ionizing radiation, which theoretically has a risk of causing cancer, there's more and more data that MRI is just as good as CT, and MRI does not use ionizing radiation. So there's probably going to be an expanding role for MRI as an alternative to CT scans. And lastly, the use of microRNA rather than just depending on serum tumor markers. So right now, we use the blood tests alpha-fetoprotein, beta hCG, extensively to monitor for relapse, and there's more and more evidence for using what we call microRNAs instead. It may be more accurate in multiple different settings. So it'll be interesting to see how that evolves and that's what I wanted to cover today. Thank you very much. Greg Guthrie: Thank you, Dr. Gilligan. And now we have Dr. Grivas, who's going to discuss some research in bladder cancer. Dr. Grivas: Thank you so much, Greg, and thanks Cancer.Net for the great opportunity to discuss this for our patients. We're very excited about the data from the ASCO Annual Meeting, and I would encourage the audience to review as possible other presentations as well. I'm going to cover 3 highlights. I'm going to start with the QUILT-3.032 study. This trial reported the final results of a clinical trial that took place in different centers and involved patients with what we used to call “superficial bladder cancer.” And the modern term is “non-muscle-invasive bladder cancer.” Bladder cancer that does not involve the muscle layers, not that deep in the bladder wall. Non-muscle-invasive bladder cancer is usually treated by our colleagues in urology with installation inside the bladder with an older form of immunotherapy which is BCG. And that's the most common way we treat this disease. And proportion of patients may have tumors that may not respond to BCG that may come back or persist despite the installation of the BCG in the bladder. And these patients usually have a standard of care of getting what we call radical cystectomy, meaning, removal of the bladder and the lymph nodes around the bladder, radical cystectomy and lymph node dissection. However, many patients may not have, I would say, the opportunity to get the surgery because the body may not be that strong to undergo that significant procedure. Very few patients may have that challenge because of other medical conditions or what we call poor performance status. Or some patients for quality-of-life reasons may try to keep their bladder as long as possible. And for some of those patients, that might be an option. And we have been looking for those options in the last few years. Intravesical, inside the bladder, installations of chemotherapy have been used with some positive results in some other studies. So that's an opportunity. We call this intravesical, inside the bladder, installations of chemotherapy, and the other option is an FDA-approved agent given intravenously inside the vein called pembrolizumab, which is in the form of immunotherapy. Of course, research continues. And this study I'm showing here from Dr. Chamie and colleagues, looked at this combination of BCG plus this molecule called N-803. This is another form of immunotherapy, and this was tested in patients who have this BCG-unresponsive, as we called it, non-muscle-invasive bladder cancer. The results were very promising. I would say impressive that it was a high response rate if we focus our attention on patients who had the superficial form carcinoma in situ, about 70% had no evidence of cancer upon further evaluation of the bladder. And in many of those patients that this response lasted for more than 2 years. 96% of patients avoided to have worsening of the bladder cancer in 2 years for those who had a response, and about 9 out of 10 avoided cystectomy again from those patients who had received the response. So it was 70% of all the population. And as you see, all patients, 100% were alive without dying from bladder cancer after 2 years, which again is a very promising finding. This combination, to conclude, this inside the bladder installations of BCG plus the N-803, looks very promising. For those patients with BCG-unresponsive non-muscle-invasive bladder cancer, that might be an option down the road, we have to see. Now I'm going to shift my attention to patients with metastatic or spread urothelial cancer. I want to point out that I'm a co-author in this abstract and I participated in that survey I will show you the results from. This is a population of patients who have spread cancer from the urinary tract, either the bladder was the most common origin or other parts of the urinary tract, for example, what we call kidney, pelvis and ureter, or rarely the urethra. The urothelial cancer that starts from those areas, again more commonly bladder, if it spreads, if it goes outside the urinary tract system, usually those patients get chemotherapy, what we call with an agent called cisplatin if they can tolerate that chemotherapy drug or carboplatin if they cannot tolerate the cisplatin drug. And usually either of these, cisplatin or carboplatin, is combined with a drug called gemcitabine. That's the most common chemotherapy used as initial therapy for patients with spread metastatic urothelial cancer. In this abstract, Dr. Gupta and colleagues tried to survey 60 medical oncologists, including myself, who treat urothelial cancer that considered experts in this disease type, to see if there are any features that could deter us from using chemotherapy in those patients. In other words, are there any features that may make us think that chemotherapy may be too risky for our patients and we should not do it? We should give immunotherapy instead. This is probably a small proportion of our patients, maybe 10 to 20% in our practice, may not be able tolerate that chemotherapy. And which are those features? Poor performance status, meaning the body is very tired and the patient is not moving too much, is confined in the chair or the bed most of the day, and rely on others on daily activities. This is what defines the performance status of ECOG 3. Peripheral neuropathy, meaning that there is numbness or tingling or weakness in the hands or the feet that impact the quality of life. And patients may have trouble buttoning buttons or tying laces, so impacting the quality of life. That's grade 2 neuropathy. Symptomatic severe heart failure, there is a grading system, like New York Heart Association Class III or IV that is significant, notable heart failure symptoms. And also, patients with kidney failure with what we call creatinine clearance below 30 cc per minute. That's a marker how we measure kidney function and the creatinine clearance more than 60 is usually close to normal. As the creatinine clearance drops and goes below 30, chemotherapy with these platinum agents may become a challenge by itself or if it's combined with the ECOG performance status of 2, which means more patients are not moving most of the day. So those features again have to do with the functionality of the day-to-day life. The presence of significant neuropathy, heart failure, and poor kidney function may potentially make the oncologist recommend immunotherapy versus the standard of care, which is chemotherapy, in those patients. And I would say if someone gets chemotherapy, which is the majority of patients, usually they may get immunotherapy later. So pretty much I would say discuss with the medical oncologist what is the right treatment for you. Most patients get chemotherapy up front, followed by immunotherapy. Some others may need to get immunotherapy, and those criteria help us make that patient selection for the right treatment at the right time. So I just alluded to you that most patients with spread or metastatic urothelial cancer, most of them receive chemotherapy. We discussed some criteria in the previous studies that we may use immunotherapy upfront instead of chemo, but for the vast majority of patients, chemotherapy is used upfront and that was based on the results of phase 3 clinical trial called JAVELIN Bladder 100. This was presented at the ASCO Annual Meeting in 2020 about 2 years ago, and it was published in a big journal. And that study showed that if you give chemotherapy upfront, those patients who can tolerate the chemotherapy, of course, who do not have the previously listed criteria, those patients benefit and live longer, so longer overall survival, meaning they live longer, and they have longer progression-free survival, meaning they live longer without worsening of the cancer if they get immunotherapy with, immunotherapy drug is given through the vein, called avelumab. If that is given after the end of chemotherapy for patients who have a response or stable disease, meaning no progression on chemotherapy. So if you get a complete response, meaning that the CAT scans look normal after chemotherapy as at least we can tell visually. Partial response, meaning that the CAT scans look better, but still we can see some cancer spots. Stable disease, meaning that the scans look stable compared to the beginning before we start chemotherapy. If someone has worsening of the cancer in chemotherapy, then the concept of maintenance therapy doesn't apply. So it's only for patients with complete response, partial response, or stable disease, SD. And the poster we had, and I can tell you - I was a co-author in the abstract and co-investigator in the trial, as a disclosure - was sort of the benefit of the patient with avelumab as maintenance therapy after chemotherapy was notable in patients with complete response, partial response, and stable disease. So in any of these 3 categories, avelumab immunotherapy should be offered as level 1 evidence and benefit patients in terms of overall survival and progression-free survival as long as there's no progression to the upfront initial chemotherapy of the patient with metastatic urothelial cancer received. Many other abstracts on these cancers were presented, and I would encourage you to look at them. Thank you so much for the opportunity today. Greg Guthrie: And thank you, Dr. Grivas. Next, we have Dr. Zhang who will discuss some research in kidney cancer. Dr. Zhang: Hi everyone, glad to be here today. I'll be discussing 2 highlights from ASCO 2022 in kidney cancer. The first one we wanted to highlight was a trial called EVEREST: everolimus for renal cancer ensuing surgical therapy, a phase 3 study. And in context, this study is a trial of evaluating everolimus, an mTOR inhibitor, in the post-surgical context. And we do have in the landscape 2 approved therapies, sunitinib and pembrolizumab. And as we have seen, some effective therapies in the refractory setting, many of these therapies are being tested in this postoperative space. So this particular study of EVEREST looked at patients with renal cell carcinoma who underwent resection for their primary nephrectomy and looking to evaluate postsurgical treatment. So everolimus has been approved as a treatment on its own in the refractory setting as well as in combination with lenvatinib. And so this question of whether everolimus alone could delay or prevent disease recurrence in the postoperative setting was tested in this EVEREST trial. The study ultimately enrolled more than 1,500 patients and assigned them to receiving either everolimus or placebo in the postoperative setting. Of these patients, 83% had clear cell kidney cancer and the remaining had non-clear cell kidney cancer. And the follow-up was quite long, over 5 years, and actually over 6 years, and the researchers looked at time until disease recurrence. And risk of recurrence was actually decreased by 15% in patients who were treated with everolimus compared to placebo. But the prespecified cut-off for a statistical significance was not quite reached, and the researchers took a specific look at a group of very high-risk patients defined by larger tumors, invasion of the perinephric fat in renal veins or invasion of nearby organs or known positive disease. And those patients with very high-risk disease had more benefit from everolimus compared to placebo. Of note, 37% of patients who were treated with everolimus had to stop treatment due to their side effects, and the most common severe side effects included mouth ulcers, high triglyceride levels, and high blood sugars. So ultimately this particular study did not show sufficient benefit of everolimus given the toxicity and lack of statistical significance. And so this is a balance between potential benefit in delaying recurrence versus treatment toxicities that we must have in this adjuvant setting. So what does this particular study mean for patients? Well, it was certainly a large phase 3 trial performed in the cooperative group setting and through the generosity of 1,500 patients and the principal investigators on the study, we learned this answer for a very important question of whether everolimus makes a difference in this postoperative setting. I think we're not using this in clinical context currently, but in this postoperative setting, we are always balancing this risk of toxicity with the potential for benefit and discussing the potential treatment options. I do not think this particular trial changes the standard of care in this adjuvant setting. And then I think finally for today's prepared talks, this abstract on depth of response and association with clinical outcomes with CheckMate 9ER patients treated with cabozantinib and nivolumab. So this was a post-trial analysis of patients who had kidney cancer with disease spread and treated with cabozantinib and nivolumab compared with sunitinib in the CheckMate 9ER study. And the context, this was the phase 3 trial in which the benefit of cabozantinib and nivolumab was established in the first-line setting and gained the registration and approval of this combination in the first-line treatment of metastatic kidney cancer. This particular analysis, presented at ASCO this year, was a post-trial prespecified analysis evaluating this depth of partial responses and associating those with clinical outcomes of time until disease progression as well as time until death. These depth of responses were defined as 80 to 100% for PR-1, 60 to 80% for PR-2, and then 30 to 60% as PR-3. And as we saw in this analysis, the deeper the responses on cabozantinib and nivolumab, the more correspondence with higher 12-month rates of disease-free progression compared with those same depths of responses from sunitinib. And there were similar 12-month overall survival rates for patients with similar depth of responses for either the cabozantinib and nivolumab combination compared with sunitinib. So I do think the degree of partial response in these settings is productive of time until progression and establishes further the efficacy and benefit of cabozantinib and nivolumab compared with sunitinib. And what does this trial mean for our patients? I think that early on, as we're looking for responses and radiographic changes for our patients on cabozantinib, nivolumab in the first-line setting, these deeper responses are associated with longer time until disease progression, and we can counsel patients, to discuss whether cabozantinib and nivolumab is working for them. This could be an early indicator for how patients will do overall on this combination. So with that I'd love to wrap up and turn it back over to you, Greg. Greg Guthrie: Thanks so much Dr. Zhang. And now it's time to move on into our Q&A session. This is for you, Dr. Agarwal. So the question is utility of triple therapy, ADT plus docetaxel plus ASI and metastatic hormone-sensitive prostate cancer given ENZAMET was inconsistent with PEACE-1 and ARASENS. Would you give ASI concurrent or sequential after chemotherapy for tolerability? I'm assuming ASI here is androgen suppression, correct? Dr. Agarwal: Yes. Great question. There are 2 questions here. Number 1, if I would use triplet therapy given the negative subgroup analysis of the ENZAMET trial, and number 2, what is the role of triplet therapy in general? The answer to the first question is ENZAMET trial, subgroup analysis is very different from preplanned, prespecified, well-powered analysis from PEACE-1 and the ARASENS trial. So yes, we saw discrepant results, but my impression from ENZAMET trial is enzalutamide is an effective option for all patients regardless of the receipt of docetaxel chemotherapy because that was a subgroup analysis. So I don't think it really affects negatively the results of the ARASENS and the PEACE-1 trial. But a bigger question here is triplet therapy versus doublet therapy? Is triplet therapy for all or doublet therapy for all? Answer is no. Triplet therapy trials only showed that adding a novel hormonal therapy or deeper androgen blockade to the backbone of ADT plus docetaxel improves survival. These trials did not answer the question, if adding docetaxel chemotherapy to ADT plus, for example, enzalutamide or darolutamide or apalutamide, will improve survival. We do not have that question answered by any of the trials and unlikely any other trial will answer that question. So my take ADT plus docetaxel is replaced by ADT plus docetaxel plus these deeper androgen blocker therapy. So wherever I was going to use docetaxel chemotherapy, so those are the patients with visceral metastases or in my practice, when I do comprehensive genomic profiling, I see those molecular aberrations which predict lack of response to deeper androgen blockade such as baseline AR variants. Or if I see 2 out of 3 mutations of p53, RB loss, p10 loss, if I see 2 out of these 3, I tend to think about docetaxel chemotherapy. So in those patients where I'm using ADT plus docetaxel, I would add another androgen receptor blocker such as abiraterone and darolutamide. But when I'm using enzalutamide or apalutamide which I use for majority of those patients, my patients with metastatic hormone-sensitive prostate cancer, I do not think about triplet therapy. Greg Guthrie: Thanks, Dr. Agarwal. We actually have a follow-up question, and this is, what is the role of oncology in low-stage early prostate cancer? Can neoadjuvant chemotherapy reduce the number of people who end up with metastatic prostate cancer? Dr. Agarwal: This answer is very simple. There is no role of neoadjuvant chemotherapy in high-risk localized prostate cancer or any localized prostate cancer setting. Greg Guthrie: Great. Thank you. Next question. I believe that this is for everybody. How long will it be until the information from the trials discussed will be used in the community clinics? What can patients do to bring this information to their less experienced doctors? Dr. Grivas: So, Greg, just to clarify the question, is it about the translation of the results of the clinic from ASCO to clinical practice, generically speaking, or any particular tumor type or any particular data results? Greg Guthrie: The way I read this question, it's more just kind of a broader scope question about just like, how long does the results of clinical trials make it to community practice, and what role can patients have in perhaps fostering this transmission of information? Dr. Grivas: Of course, I can start briefly, and then my colleagues can add. I would say the world we live in right now, the information travels very quickly. It's much faster compared to the past. And I think there is much more alignment, in my opinion, in terms of information access between academic oncologists and community oncologists. If, for example, a trial result comes at ASCO being presented, and then there's a follow-up approval authority from a regulatory agency, this agent may be accessible to both community and academic practices. Of course, there are always opportunities for education, and Dr. Agarwal is the director of the ASCO Daily News, and he knows that well to disseminate the information well, broadly, in an equitable manner across academic oncologist providers and community providers. And I think CME, continued medical education practices, can help in that regard. And obviously, the other aspect of that is the ongoing clinical trials and how we can do a better job disseminating the opportunity for equitable participation in clinical trials across racial groups, ethnicity groups, minority groups, to give them the chance to participate in ongoing clinical trials that may change the practice down the road, which are just early thoughts. But other colleagues can comment. Dr. Zhang: Yeah, if I could chime in. I think these continuing medical education programs, particularly in the context after large symposia like the ASCO Annual Meeting we just had, are particularly important. And the Best of ASCO series, as well as ASCO Direct Highlight series - I believe Dr. Grivas and I are hosting 2 of these - are very helpful, I think, to bring the latest findings from the ASCO Annual Meeting to our community colleagues. And they really are our colleagues. We work together with our oncologists within the community to take care of our patients, oftentimes for standard of care treatments. Patients can access them more in their backyards. And I think from a patient standpoint on the second part of the question, they're able to hear these from patient-friendly platforms and to bring that to the attention of their oncologist, wherever that may be. It all helps in the grand context of clinical care. So I hope that these trial results and the latest findings from ASCO can get inseminated very quickly.   Dr. Grivas: And to also add very briefly, the role of patient advocacy groups, and in the bladder cancer work, there are many, for example, the Bladder Cancer Advocacy Network, World Bladder Cancer Coalition, and many others can help also in that regard and teaming up with all of us to disseminate information and also clinical trial access. Greg Guthrie: Great. Thank you, everyone. We have a question for Dr. Grivas. After the survey results in the study you described, is there any plan to make a guideline or tool to make sure we standardize the definition of cisplatin/platinum ineligibility? Dr. Grivas: Great question. Just 1 more thing on my prior answer, kudos to Cancer.Net for serving that mission, Greg and Claire in that-- or the previous question to have a complete answer. Answering this new question here, which is very important. I think the next step is to try to publish the results of the survey. The survey like the previous one done by Dr. Galski about 10 years ago-- it's a survey on expert oncologists, and it's a consensus-based definition. It's criteria that we came up with together. And I think the next step here is to publish this in a peer-review process. And our hope is by publishing these results, we can have a more formal definition to help guide our practices in academia, but also in the community oncology practices and make sure that we have a standardized way that we approach this therapy selection and of course, to help design clinical trials that for this particular patient population in order to improve outcomes in this setting. So hopefully publication will come soon. Greg Guthrie: Thanks, Dr. Grivas. I'll just drop a really quick pitch there. Here at Cancer.Net, we do have a very broad array of information on clinical trials. And patients can come visit us at Cancer.Net and learn about clinical trials, what they mean, and how they help advance cancer research. We now have a question for Dr. Zhang. Based on the results of EVEREST and other trials approved systemic therapies in the adjuvant setting like sunitinib and pembrolizumab, are there ongoing other trials in this setting and is risk stratification used? Dr. Zhang: The short answer is yes. There are ongoing adjuvant trials that build on pembrolizumab in the adjuvant setting. There's one that is looking at the addition of belzutifan with pembrolizumab in the adjuvant setting. So that trial is a global trial which is about to get started, if not enrolling already. And in the context of adding on in the adjuvant setting, I do think we really need to discuss with our patients how much of a benefit the treatment will have versus the real toxicity in the postoperative setting, many patients will not have symptoms from their cancer, so they may have some pain or healing side effects from surgery, but they won't have symptoms from cancer. So any toxicities from medications can be further amplified, so are we truly giving a lot of benefit in that context or not. So that's an individualized decision, and I do think conversations must be had to make that decision together. Greg Guthrie: Thanks, Dr. Zhang. I want to ask a question myself of Dr. Gilligan. You had mentioned that microRNA is an emerging field of study, and I've heard about this in other types of cancer as well. I wonder if you could discuss that a little bit more. Dr. Gilligan: Yeah, microRNA, the promise that holds is being a more accurate detector, specifically of testicular cancer. So the problem we have with alpha fetoprotein and beta HCG is half of the testicular cancers may not make 1 or both of those markers. So people can relapse without the markers going up, even though markers are most commonly what we see, there are a couple of different scenarios. Someone has stage I testicular cancer, which means their testicles removed and all their scans show no evidence of cancer. We know that 25% or so of non-seminomas and 20% or so of seminomas will relapse, even though we can't see what the cancer is, and the markers are negative in that situation. MicroRNA may be able to detect those people who still have cancer much, much earlier. So we know that they're, in fact, not stage I and that they need active treatment right away. So that's one place. Another place that we're seeing evidence is that men who've had metastatic testicular cancer. They go through chemotherapy, and they have residual masses. And we're wondering if there's cancer in those masses or is it all dead scar tissue or is it teratoma? MicroRNAs may be able to allow us to determine who needs additional treatment, who needs surgery without having it. Right now, we typically go in and operate just to figure that out. So there are a number of situations in which we could more accurately stage patients and figure out who's cured and who's not cured much earlier in the course of disease. And for a patient, this would be fantastic, because right now, if you've got stage I disease with non-seminomas and you go on surveillance and somebody says you have a 25% risk the cancer is going to come back, that's a 1 in 4 chance that at some point in the next 2 years, most likely, or longer, you're going to have to suddenly drop everything and go through months of chemotherapy. If we knew on day 1, it looks like you're cured, but in fact, there's cancer hiding there somewhere, and we need to treat you now, that would be helpful to know so they can get it over with. And the other men, we could say we're really extremely confident that there's not a 25% risk, it's a 5% risk or something much lower. So there are a number of ways, if this really gets proven and there's emerging data that's promising, I think we could reassure men, treat them more appropriately, spare them unnecessary treatment, and give them more peace of mind. Greg Guthrie: Great. Thanks, Dr. Gilligan. I think we have a question from Dr. Grivas now. Dr. Grivas: Thank you, Greg. This is a great panel. I like to learn from my colleagues here. One question for Dr. Zhang, you have done so much work in the field, leading the field there, Dr. Zhang. Any comments about the ideal end points in the adjuvant setting in kidney cancer, urothelial cancer, disease-free survival or overall survival? Would you comment about how we design trials, and what will be an acceptable benchmark? And what is meaningful for patients, too, in the adjuvant treatment after radical surgery for kidney cancer and urothelial cancer? Dr. Zhang: Oh, that's a great question, Petros. Thank you so much for asking. We have discussed this many times together because you and bladder cancer and myself and kidney cancer, we're thinking a lot along the same lines right as new immunotherapies get approved in the postoperative setting, so disease-free survival as an endpoint and recurrence-free survival as an endpoint is a valid endpoint. It's a direct result of the randomized treatment on the trial, so I do think that is the valid endpoint, and it's an endpoint that the FDA has approved the sunitinib and pembrolizumab indications in kidney cancer, nivolumab and bladder cancer. So I think it's certainly a valid endpoint to delay disease recurrence. How much of that is meaningful degree of improvement for an individual patient? Their own measure of recurrence is either yes or no. It's much more binary than population effects. So how much does that translate into benefits for the patient? I think that warrants deeper individualized discussion. But these disease-free survival endpoints in all of these studies is a valid endpoint to see whether the treatment is worthy in delaying disease recurrence in each of these disease types. Greg Guthrie: Thanks, Dr. Zhang. We have one last question here, and I believe this is a follow-up for Dr. Gilligan. And what is the time frame for the rollout of microRNA 371 to the community? Dr. Gilligan: I don't know the answer to that. I'm not sure that we have enough data right now that it's going to get approved. I think we're headed in the right direction, but it's very hard to know what the timing of that is. There are trials going on, so I don't know at the moment of exactly what the scenarios are in which people are going to be, which patient populations are going to be eligible, but there are trials going on. I think I'm hoping within the next 2 years or so, but I really don't know what the time frame is, unfortunately. Dr. Grivas: And if I may add a more generic comment to Dr. Gilligan's wonderful answer is that when we have what we call biomarkers that are like metrics that can give us information about how the patient does over time, it's important to tease out what we call prognostic, meaning how can this biomarker give us a sense of the chance of recurrence, as Dr. Gilligan said, or death from the cancer. But also, the bigger question is, is it going to give us information to predict benefit from an individual therapy? And that's a bigger question in oncology that is a harder one. This predictive question and try to identify biomarkers and validate them to make sure they have, they're clinically useful. They can help us make treatment decisions in the clinic. And I'm very excited about what Dr. Gilligan discussed about the promise in the future. But more trials are needed for many biomarkers. Dr. Gilligan: I think when we do this update next year, we'll have significantly more data then, I'm hopeful. Greg Guthrie: Thank you to you all. Thank you, Dr. Agarwal. Thank you, Dr. Grivas. Thank you, Dr. Gilligan. Thank you, Dr. Zhang, for sharing this great research with us, as well as your expertise. It's been a real pleasure this afternoon. And to all of our viewers, thank you for joining us. You can find more coverage of the research from ASCO Annual Meeting and other scientific meetings at the Cancer.Net blog, which is at www.cancer.net/blog. And if you're interested in more Cancer.Net content, please sign up for a monthly Inside Cancer.Net newsletter or follow us on social media. We're on Facebook, Twitter, and YouTube where our handle is always @CancerDotNet, with dot spelled out. Thank you all, and be well. Thanks. ASCO: Thank you, Dr. Agarwal, Dr. Gilligan, Dr. Grivas, and Dr. Zhang. You can find more research from recent scientific meetings at www.cancer.net. Cancer.Net Podcasts feature trusted, timely, and compassionate information for people with cancer, survivors, and their families and loved ones. Subscribe wherever you listen to podcasts for expert information and tips on coping with cancer, recaps of the latest research advances, and thoughtful discussions on cancer care. And check out other ASCO Podcasts to hear the latest interviews and insights from thought leaders, innovators, experts, and pioneers in oncology. 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