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What if your dreams could predict disease, unlock creativity, reveal hidden trauma—and even be controlled? Dr. Rahul Jandial, MD, PhD (dual-trained neurosurgeon and neuroscientist, founder of the Jandial Lab at City of Hope Cancer Center in Los Angeles, and bestselling author of This is Why You Dream) takes you inside the wild, cutting-edge world of dream neuroscience and the sleeping brain. Discover how this top brain surgeon can create a memory of a nightmare during awake brain surgery, what the brain does just before death, and how dream patterns may predict neurological disorders like Parkinson's disease. Learn why erotic dreams occur, how lucid dreaming can enhance your waking life, what happens during sleep paralysis, and why some people don't remember their dreams—plus expert sleep tips to improve dream recall. Dr. Jandial also explores the deep links between trauma and nightmares, depression, and the eerie science of precognitive dreams and near-death experiences (NDEs). From the universal themes of falling and flying dreams to the latest on how AI might already be hacking your dreams, this is everything your brain's doing while you sleep—and why it matters more than ever. Dr. Rahul Jandial's book, THIS IS WHY YOU DREAM: What Your Sleeping Brain Reveals About Your Waking Life: https://www.penguinrandomhouse.com/books/735627/this-is-why-you-dream-by-rahul-jandial-md-phd/ Follow us on Substack for Exclusive Bonus Content: https://bialikbreakdown.substack.com/ BialikBreakdown.comYouTube.com/mayimbialik
What if your dreams could predict disease, unlock creativity, reveal hidden trauma—and even be controlled? Dr. Rahul Jandial, MD, PhD (dual-trained neurosurgeon and neuroscientist, founder of the Jandial Lab at City of Hope Cancer Center in Los Angeles, and bestselling author of This is Why You Dream) takes you inside the wild, cutting-edge world of dream neuroscience and the sleeping brain. Discover how this top brain surgeon can create a memory of a nightmare during awake brain surgery, what the brain does just before death, and how dream patterns may predict neurological disorders like Parkinson's disease. Learn why erotic dreams occur, how lucid dreaming can enhance your waking life, what happens during sleep paralysis, and why some people don't remember their dreams—plus expert sleep tips to improve dream recall. Dr. Jandial also explores the deep links between trauma and nightmares, depression, and the eerie science of precognitive dreams and near-death experiences (NDEs). From the universal themes of falling and flying dreams to the latest on how AI might already be hacking your dreams, this is everything your brain's doing while you sleep—and why it matters more than ever. Dr. Rahul Jandial's book, THIS IS WHY YOU DREAM: What Your Sleeping Brain Reveals About Your Waking Life: https://www.penguinrandomhouse.com/books/735627/this-is-why-you-dream-by-rahul-jandial-md-phd/ Follow us on Substack for Exclusive Bonus Content: https://bialikbreakdown.substack.com/ BialikBreakdown.comYouTube.com/mayimbialik
Dr. David Winchester from the City of Hope Cancer Center discusses skin cancer prevention, screening, and treatment. Meteorologist Justin Gibbs from the National Weather Service in Paducah, KY talks rain totals in southern Illinois following last week's storm system.Joe Camp at Commstock Investments previews a new market week.
Send us a textRobert Stone is the CEO of City of Hope ( https://www.cityofhope.org/robert-stone ), a premier cancer research and treatment center dedicated to innovation in biomedical science and the delivery of compassionate, world-class patient care. A seasoned health care executive, he has served in a number of strategic decision-making roles since he joined City of Hope in 1996, culminating with his appointment as president in 2012, CEO in 2014, and as the Helen and Morgan Chu Chief Executive Officer Distinguished Chair in 2021.Mr. Stone has J.D., University of Chicago Law School, Chicago, IL.Mr. Stone's strategic acumen, empathy and visionary leadership have driven City of Hope's rapid evolution. As an independent institution dedicated to advancing the fight against cancer and diabetes, City of Hope is accelerating opportunities for high-impact discovery and ensuring that patients around the world have access to the most advanced therapies. Recent examples include a groundbreaking alliance in precision medicine with the Translational Genomics Research Institute (TGen), a leader in genomic analysis and bioinformatics; leadership in CAR T cell therapy research and therapy; and an innovative program to offer cancer support services to the employees of some of American's largest employers, regardless of geography.Dr. Marcel van den Brink, M.D., Ph.D.( https://www.cityofhope.org/marcel-van-den-brink ), is President of City of Hope Cancer Center, main campus in Los Angeles, and National Medical Center, chief physician executive and the Deana and Steve Campbell Chief Physician Executive Distinguished Chair, and is a globally recognized leader in the basic and translational science of bone marrow transplantation (BMT), the microbiome and cancer immunotherapy. His specialties include immune reconstitution and graft-versus-host disease — side effects many BMT patients experience — as well as the impact of the microbiome on immunotherapy for cancer. A researcher who has opened new fields of investigation and improved patient outcomes, Dr. Van den Brink has pursued innovative ways to improve and optimize BMT, developing strategies to make the process less toxic and lower the rate of recurrence. Throughout his career, he has maintained an intense focus on converting scientific discoveries in his laboratory into better therapies for patients around the world.Dr. Van den Brink joined City of Hope in part because of their shared commitment to advancing the frontiers of cancer care and research. He is known for his inclusive approach to leadership and his devotion to providing junior faculty colleagues with mentorship and career development opportunities.A recipient of numerous national and international awards, Dr. Van den Brink is a member of the Royal Netherlands Academy of Arts and Sciences. Among many leadership roles, he serves as vice chair of the board for Deutsche Knochenmark Stiftung, a global donor registration that facilitates 40% of all unrelated allogenic blood stem cell donations worldwide.Dr. Van den Brink has a Ph.D., Medicine (Immunology), and M.D., Cum Laude, University of Leiden, The Netherlands, completed a postdoctoral fellowship at the Pittsburgh Cancer Institute in Pittsburgh, PA and residency at Duke University Medical Center in Durham, NC. #Cancer #Oncology #CityOfHope #RobertStone #MarcelVanDenBrink #Microbiome #Immunotherapy #CarT #Thymus #ThymicInvolution #Regeneration #BoneMarrowTransplantation #TranslationalGenomicsResearchInstitute #PrecisionMedicine #GraftVersusHostDisease #ProgressPotentialAndPossibilities #IraPastor #Podcast #Podcaster #ViralPodcast #STEM #Innovation #Technology #Science #ResearchSupport the show
After a long day when we lay down to rest, that's when our brains really fire up to help us dream. Dr. Rahul Jandial is a neurosurgeon and neuroscientist who oversees the Jandial Lab at City of Hope Cancer Center in Los Angeles. He joins host Krys Boyd to discuss how dreams help or brains function, why they are essential to memory and why dreams across cultures are remarkably similar. His book is “This Is Why You Dream: What Your Sleeping Brain Reveals About Your Waking Life.”This episode originally aired on June 4th, 2024.
After a long day when we lay down to rest, that's when our brains really fire up to help us dream. Dr. Rahul Jandial is a neurosurgeon and neuroscientist who oversees the Jandial Lab at City of Hope Cancer Center in Los Angeles. He joins host Krys Boyd to discuss how dreams help or brains function, why they are essential to memory and why dreams across cultures are remarkably similar. His book is “This Is Why You Dream: What Your Sleeping Brain Reveals About Your Waking Life.”
“The HemOnc Pulse” goes on the road to Chicago May 3-4 with host Chadi Nabhan, MD, MBA, FACP, for the first live meeting. This podcast episode features a panel discussion on unanswered questions in chimeric antigen receptor (CAR) T-cell therapy with Caron Jacobson, MD, MMSc, Medical Director of the Immune Effector Cell Therapy Program at Dana-Farber Cancer Institute; Michael Bishop, MD, FACP, FASCO, Director of the Hematopoietic Stem Cell Transplantation Program at the University of Chicago; Joseph Mikhael, MD, MEd, FRCPC, FACP, a Professor in the Applied Cancer Research and Drug Discovery Division at the Translational Research Institute, an affiliate of the City of Hope Cancer Center; and Alan Skarbnik, MD, Director of the Lymphoma and Chronic Lymphocytic Leukemia Program and Director of Experimental Therapeutics, Malignant Hematology at Novant Health.
Don't miss The Balm In Gilead's Multiple Myeloma Spotlight on our website!This week's guest, Dr Joseph Mikhael MD, MEd, FRCPC, FACP, leads the M-Power project in the African American community for the International Myeloma Foundation (IMF). Dr. Mikhael is a Professor in the Applied Cancer Research and Drug Discovery Division at the Translational Genomics Research Institute (TGen), an affiliate of City of Hope Cancer Center. He is the Chief Medical Officer of the IMF and Director of Myeloma research at the HonorHealth Research Institute. Dr Mikhael specializes clinically in plasma cell disorders, namely multiple myeloma, amyloidosis, and Waldenstrom's macroglobulinemia. He is the PI of many clinical trials, primarily in relapsed multiple myeloma, and his other clinical research interests include pharmaco-economics, communication skills, and media relations. Dr. Mikhael also serves as the Treasurer on the executive board of the American Society of Hematology. Dr Mikhael has published over 200 peer-reviewed articles in these fields, and lectures internationally on a regular basis. He is also the chair of the Diversity, Equity and Inclusion Council at TGen. Dr. Mikhael is heavily involved in training future researchers, and mentors junior faculty worldwide. He also spends nearly 20% of his time in the third world developing collaborations in myeloma and finding ways to enhance access to novel treatment agents.
Dr Joseph Mikhael from the City of Hope Cancer Center in Phoenix, Arizona, discusses recent updates and future directions in the management of newly diagnosed and relapsed/refractory multiple myeloma.
Dr Joseph Mikhael from the City of Hope Cancer Center in Phoenix, Arizona, discusses recent updates and future directions in the management of newly diagnosed and relapsed/refractory multiple myeloma. CME information and select publications here (https://www.researchtopractice.com/OncologyTodayPostConf23/MM)
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 September 2022, ASCO and the Society for Integrative Oncology, or SIO, published a joint guideline on using integrative therapies to manage pain in people with cancer. Integrative therapies are treatments and techniques used in addition to standard cancer treatment to help people cope with the side effects of cancer, including cancer-related pain. In this podcast, Dr. Richard Lee talks to the guideline panel co-chair, Dr. Jun Mao, about these guideline recommendations. They discuss why the guideline was created and the different types of integrative therapies included in these recommendations, including acupuncture, reflexology and acupressure, hypnosis, massage, yoga, guided imagery and progressive muscle relaxation, and music therapy. Dr. Lee is a clinical professor in the Departments of Supportive Care Medicine and Medical Oncology at City of Hope Comprehensive Cancer Center and serves as the medical director of the Integrative Medicine Program. Dr. Lee is also the 2023 Cancer.Net Associate Editor for Palliative Care. Dr. Mao is chief of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center and holds the Laurance S. Rockefeller Chair in Integrative Medicine at the institution. View disclosures for Dr. Lee and Dr. Mao at Cancer.Net. Dr. Lee: My name is Richard Lee. I'm a clinical professor here at City of Hope Cancer Center. I'm in the Departments of Supportive Care Medicine and Medical Oncology and medical director for the Integrative Medicine Program. I'm honored to be accompanied today by Dr. Jun Mao. He's the chief of the Integrative Medicine Service at Memorial Sloan Kettering and holds the Laurance S. Rockefeller Chair in Integrative Medicine. So we're going to talk about the joint SIO-ASCO guidelines that recently came out in the Journal of Clinical Oncology looking at integrative approaches to cancer pain. And so let me first ask you, Jun, could you talk about what is a clinical practice guideline, and how does it help guide cancer care? Dr. Mao: The clinical practice guideline is a process bringing multidisciplinary experts to look at the evidence from randomized clinical trials or systematic reviews and meta-analysis and to really evaluate the level of the evidence from research and clinical trials, and also incorporate our clinical expertise, consideration for the benefit and risk. Then, making a set of recommendations for doctors and nurses, health care providers to make informed decisions for patients. Dr. Lee: Great. And tell us more, what is integrative medicine for those patients who may not have a full understanding what this field is about? Jun Mao: So integrative medicine is a complex term. Originally, a lot of people may have heard that term of “alternative medicine” or “complementary medicine.” So those terms are referring to using things like herbs or shamanism instead of a conventional cancer treatment. So recognizing the needs of patients who want to explore alternative ways to help them to cope with cancer, and the importance of adhering to conventional surgery, radiation therapy, chemotherapy. So the field of integrative medicine has emerged. Integrative medicine is a field that is based on evidence and acknowledge the patient's wishes to carefully incorporate evidence-based lifestyle interventions, mind-body treatments, and consider for natural products and herbal medicine in a safe and effective way to improve patients' physical, emotional, and spiritual well-being. Also, part of the goal of integrative medicine is to really engage the patient as an active participant to prevent cancer and to really engage in their own care during and beyond their cancer treatment. Dr. Lee: And for patients who are new to this concept of integrative medicine or integrative therapies, why is it important for us to study this for cancer care? Dr. Mao: Richard, this is really important because often when a person gets cancer, you get friends and family who really want to be helpful who say, “Do this, try that, use this herb, or this supplement has been used by that.” So there's a lot of anecdote. There's a lot of sort of people just want to be helpful. But in actuality, some of the treatments, without carefully considering actual evidence and potential risks of drug herbal interaction, can induce harm, not only increase the toxicity of the cancer treatment, but may even shorten the lives of cancer patients. Therefore, we often tell patients don't use these treatments as alternative, but to use in an integrated way. And doing research is going to be helpful to understand in what setting for what condition or symptoms. These are helpful, not helpful, are they safe or unsafe? Dr. Lee: That's really important. That's great to see the research coming along. And so let's talk about ASCO, the American Society for Clinical Oncology, which is the world's leading and largest professional organization for oncologists, as well as Society for Integrative Oncology, SIO. You know, how did they come together to produce this joint guideline on integrative medicine and pain management? Dr. Mao: So, as you know, ASCO is a world-leading conventional oncology society. It's a multi-discipline, you know, surgeons, medical oncologists, radiation oncologists, a lot of psychosocial supportive care folks are part of this society. Society for Integrative Oncology is a relatively new society, but this year we're celebrating 20th year, so it's not so new anymore. You know, a lot of very passionate physicians, nurses, nutritionists, social workers, we joined together to really help to advocate for evidence-based integrative medicine in the context of care delivery. SIO brings that expertise together with ASCO to formulate a set of guidelines that can be readily implemented into the care setting to help patients and families to deal with pain, a very common and disturbing side effect for cancer and cancer treatment. Dr. Lee: It's so great to see 2 leading organizations come together to put these guidelines together. So let's jump into the guidelines a little bit, and one of the areas that they covered is acupuncture. So can you let us know and let patients know what is acupuncture, and what types of cancer-related pain has it been shown to be helpful? Dr. Mao: Acupuncture is a type of therapy that originated from the traditional Chinese medicine. It has been documented over 2,500 years ago. So the way acupuncture works clinically is putting very thin, sterile needles in specific locations of the body to help address symptoms, promote a sense of relaxation and wellness. Often, you need a series between 6 to 10 treatments. I always tell patients it's almost like a physical therapy. You need a few treatments to see the benefit. In animal research, there has been a documented mechanism that acupuncture may help your brain to release endogenous neurotransmitters, like endogenous opiates, serotonin, or dopamine, as a result to reduce pain, increase a sense of relaxation, well-being. So the ASCO-SIO Joint Clinical Guideline looked at clinical trials, found pretty strong evidence that acupuncture can be used for a type of joint pain that is very common in women with breast cancer taking aromatase inhibitors. Aromatase inhibitors are a class of drug that drop the estrogen level in women with breast cancer as a result of preventing the breast cancer from spreading. Unfortunately, about 50% of women do develop very diffuse joint pain. A lot of time it is in the low back and knees and makes a lot of patients stop this life-saving drug. The committee feels strongly like acupuncture should be recommended as one of the options to treat aromatase inhibitor-related joint pain. In other areas, not as strong, but also in general cancer-related joint pain and musculoskeletal pain. And there are also some weak evidence on acupuncture can be helpful for chemotherapy-induced peripheral neuropathy, as well as to be used in post-surgical related pain. So those are the recommendations we would tell a patient who experienced those pains to try acupuncture. Dr. Lee: So Jun, you mentioned about the different recommendations around acupuncture, and you're talking a little bit about levels of evidence. Could you explain to patients what you mean by the levels of evidence and the types of recommendations that were put forward by ASCO and SIO? Dr. Mao: So when experts review evidence from clinical trials, if you have several large clinical trials producing very consistent findings that a therapy is beneficial with very low risk, that will give you a high level, strong quality of evidence with strong recommendation. Unfortunately, in the field of integrative medicine, often there's a lack of funding for this type of research. So what you do see is there are maybe only 1 trial showing that it's very beneficial and maybe there are some smaller trials to show some signal, then we will give an intermediate quality of evidence and moderate strength of recommendation. And then you have therapies that are being used by patients, but there's very little trials or the trials, the sample size are very small. Sample size means how many patients participate. Then you see some promising signals overall, but it's kind of, you know, we don't have a strong confidence in the result. That's where we give low quality of evidence and weak strength of recommendation. Dr. Lee: That's really helpful and it's, I think, important since integrative medicine is really based on evidence-based approaches that we are looking at the levels of evidence. So thank you for explaining that. Let's move on to some other therapies that were mentioned within the guidelines. You talk about reflexology and acupressure. Can you talk about what these types of therapies are and what have they been shown to help? Dr. Mao: So reflexology acupressure, so this is a very similar sort of a principle of treatment, but instead of putting needles, it's actually a therapist will put hands on or teach the patient to press specific acupuncture or pressure points as a result to reduce pain or induce relaxation. So here is where you see some intermediate quality of evidence with moderate strength of recommendation for general cancer pain or musculoskeletal pain as the patient is receiving treatment. One common area you would see that is sometimes when a patient's getting chemotherapy, they will have these muscle aches and joint pain. It's not long lasting, but it's very annoying for a number of days. So in those settings, you can try that. Dr. Lee: So for patients who might have a needle phobia and are very hesitant, would it be reasonable for them to think about reflexology and acupressure as another modality? Dr. Mao: Oh, absolutely. And also I want to clarify reflexology often is done on the feet. So a lot of patients may not necessarily like general massage. Some people love it, but other people just don't want people to touch their whole body. Then the reflexology just focusing on massaging the feet or lower legs can be a really good option. Dr. Lee: Yeah, great to see there are options for patients, depending on their preferences. Let's move on to another therapy in the guidelines that mention hypnosis. And so a lot of patients may not be familiar with what is hypnosis and where can that be applied for patients with cancer? Dr. Mao: Hypnosis is really about changing a state of awareness and a sense of increased relaxation that often allows for improved focus or concentration. But when you talk about hypnosis in a health care setting, it is often done by a provider with verbal repetition, provided with some mental images. Often during hypnosis, patients can be taken to a different mental place and feel a sense of relaxation and calm. And where you see some evidence is actually for procedural pain. This is derived from a large, randomized trial for biopsy, as well as some interventional procedure showing that hypnosis produces benefit for pain reduction, more of acute pain relief. Again, it makes sense physiologically, right? You take your mind and consciousness to a different place rather than focus on the procedure and pain. So this is where we give intermediate quality of evidence and moderate strengths of recommendation. Dr. Lee: Mm-hmm, good. And let's talk a little bit more about massage. You mentioned that a little bit when you were talking about reflexology. Can you tell us about what situations might massage be helpful for the patients? Dr. Mao: So massage, many people know is really applying pressure in a specific body area. And certainly, for oncology massage, people need to have some specific training to be safe, make sure people don't put pressure in where the tumor is or where there may be fracture risk for bone metastasis as well as in where their medical port is. So I would advise patients work with people who have specialized oncology training. With that said, I think we find really good evidence, particularly in the area of use in palliative care. So there was a large trial with over 300 people randomized to either massage or just gentle touch. Massage reduced pain and improved mental health. So I would say massage to be utilized in patients living with advanced cancer or for patients in a hospice setting can be a really beneficial tool. Where there is a slightly, sort of a weaker evidence I would say, is in the area of a general musculoskeletal pain as the patient is experiencing treatment or in survivorship. There, we give a low quality of evidence, but a moderate strength of recommendation. The reason we give a moderate strength of evidence is the risk is really minimal, right? Like even though we don't have a good amount of research, but even say massage produces some temporary relief, it can still be very beneficial for the patients. Dr. Lee: And let's shift gears a little bit to something called yoga, which many of us may know from your local gym. Can you talk a little bit about yoga and what does that mean for patients who have cancer, and how can that help with cancer-related pain? Dr. Mao: Yoga, as many of you know, originated from India, maybe even as old as 5,000 years ago. So yoga practices, it really combines breath work with meditative work with posture, right, specific postures. So often we know in routine, just health industry, yoga can be really good for physical balance, for flexibility, for induced sense of relaxation. So less is known about the use of that for pain management. So there were some small studies to show that yoga showed really good potential benefit in addressing aromatase inhibitor-related joint pain. The reason we give it a low quality of evidence and weak strength of recommendation is because the research is not as developed in this area. Also, in one of the trials, the pain was the secondary outcome rather than the primary outcome. So it was not the outcome they hypothesized to find, although they did find some benefits. So with that, we do feel like given how yoga is relatively low risk, it's very accessible. So it could be considered for women with breast cancer experiencing aromatase inhibitor-related joint pain. Dr. Lee: And then, Dr. Mao, could you comment a little bit about--there's so many different styles of yoga. Some of them are very physical, like the kind of hot yoga versus other styles might be more gentle. Can you comment a little bit about that and in terms of what style patients might want to consider? Dr. Mao: There's also a national organization to help to train yoga instructors to work with cancer survivors. So as you look out for those programs, you should really look at people who have those experiences. And I would say most of the studies use more of a hatha type of, more gentle yoga rather than the probably rigorous sort of yoga. Particularly, I would say for women with breast cancer on hormonal drugs, there's higher risk for osteoporosis. So it's important to consider the risks. And I would work with highly experienced instructors rather than trying very risky moves that potentially can cause musculoskeletal injuries or fractures. Dr. Lee: Good things to keep in mind as you think about these different therapies. Let's focus more on these kinds of what some consider mind-body techniques: guided imagery, progressive muscle relaxation. Can you talk about these types of therapies, and can the 2 techniques be used in combination to help with cancer pain? Dr. Mao: So these are very common techniques in the realm of mind-body and relaxation technique. Often you will listen to words and the words will guide you to imagine you're on a beach or hiking in the green meadows. And often there's nice music along with the verbal suggestions. And with progressive muscle relaxation, sometimes we'll ask you to squeeze certain muscle and then release, squeeze and release. By doing that, it also causes a sense of relaxation. So where the application for this is where you see in general cancer pain or musculoskeletal pain. So in those settings, this can definitely be elements to help you improve the coping of pain, it's almost in the realm of self-care. So patients can potentially do that at home. However, I would say the evidence still very low. So the quality of evidence we give is a low quality of evidence and weak strength of recommendation. Although this therapy is very intuitive, they cause relaxation, which should help with pain. But I would say they by themselves may not be... the primary mode to manage pain, but rather than improve the coping of pain. Dr. Lee: And let's shift gears a little bit to other techniques. One that was mentioned was music therapy. And of course, a lot of people listen to music on the radio or on the way to work. Can you talk about what is music therapy? Is that the same as just turning on the radio, and where can that be helpful for pain management? Dr. Mao: So I'm so glad you're asking this question because music therapy is not just music. Music therapy is working with a specialized trained therapist to use music as an avenue to allow patients to develop a very meaningful therapeutic report to induce relaxation, to manage specific physical and emotional symptoms such as pain, depressive symptoms, anxiety. So often, you know, either through playing an instrument, creating sounds, and sometimes by passive listening and passive relaxation. So it's a very sort of an involved process. Where I think there are currently some weak levels of evidence is music therapy for post-operative for surgical pain. That's where there are some research, but because of the trial, the sample size and the control, so unfortunately we can only give a low quality of evidence and weak strength of recommendation. There's much more knowledge about the use of music therapy to reduce anxiety and depression. So, and often those psychological symptoms go hand in hand with a patient with pain. So I do think when we talk about pain management, we shouldn't be so reductionist to just think of a person with pain. Often you have pain, you have anxiety, then you feel depressed about the pain, right? So I think music therapy can play a role to improve the mental coping with pain. Dr. Lee: I think you bring up a really great point, Dr. Mao, about for patients who are being evaluated for pain to really work with their medical team to explore all the potential factors that might be contributing to the pain. Not only their cancer or the treatment, but their mood or how they're sleeping might play a factor. Dr. Mao: Rich, as you know, I'm an integrative medicine specialist. So when we work with patients, we really take a comprehensive history to really understand what are the symptoms. Often, I have never seen patients just presenting with one symptom, right? So then you'll understand their symptoms and needs and then help them to prioritize what matters the most for them and which therapies potentially have the biggest bang for the buck to improve the things they want to help the most. And then often those therapies will produce some, what I call the “side benefit,” say by improving pain, also improve your sleep, improve your anxiety. So the mechanism may be slightly different, and also patients may have different preference. Some people love yoga, other people would never try it. So you got to really, this is what the beauty is about integrative oncology, to give that choice and control back to the patients. But really, as physicians, we provide them with the evidence to help them to make informed decisions. Dr. Lee: And what do you think are the kind of key takeaway points a patient should think about based on these guidelines? Dr. Mao: I think the key takeaway is when you experience pain, don't just think about drugs. Really think about, there are evidence-based non-pharmacological interventions that can really potentially help you reduce pain, improve your emotional and physical coping with the pain. So talk to your doctors and nurses. Are there those therapies available in your cancer center or clinical practice? Or connect you with the qualified community providers and be a strong advocate for your own health. Dr. Lee: And for patients who really want to dive deep and learn more about these, where would you suggest they go to learn more about integrative therapies for cancer-related pain? Dr. Mao: Yeah, as a patient as well as a family member, it's really important to go to websites that are credible for reliable information. So, ASCO has Cancer.Net. It provides incredibly valuable information for patients and families impacted by cancer. American Cancer Society will be a good resource as well. National Cancer Institute also have monographs for integrative therapy, so those can be really valuable. Other places like a Society for Integrative Oncology website or Memorial Sloan Kettering Cancer Center website also have a lot of information about integrative therapies. Dr. Lee: So this has been wonderful. I really want to thank Dr. Mao for a great overview regarding the ASCO-SIO joint guidelines on pain management. And you mentioned a lot of great websites, including Cancer.Net, in which you can learn more about these guidelines as well as other therapies to help with your care. Dr. Mao: Dr. Lee, thank you so much for doing this really important podcast. I do think as one of the co-chairs for this committee, our group really aspired to use this set of ASCO-SIO clinical guidelines to make integrative therapies part of comprehensive pain management for patients impacted by cancer. And together, we can move closer to allow cancer patients to have lower symptom burden, high quality of life. Dr. Lee: I really congratulate you and Dr. Bruera for a job well done, co-chairing this really large effort. It took a lot of time. We're looking forward to additional guidelines coming out from ASCO and SIO looking at different symptoms. ASCO: Thank you, Dr. Lee and Dr. Mao. Learn more about integrative medicine at www.cancer.net/integrative. 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.
In this episode, Drs. Lemanne and Gordon discuss research on the role of fasting in the treatment and prevention of cancer. Dr. Lemanne discusses her personal experience of fasting, and how she uses fasting in the cancer clinic.Exactly when to fast for best cancer outcomeCombining fasting and chemotherapy improves survival--animal studiesTypes of fasts, including water fasts and dry fastsResearch on dry fasting and kidney function (prepare to be surprised)Eating dinner late increases cancer riskDaily intermittent fasting, minimum effective lengthExtended fastsMeth EMS, van Egmond LT, Moulin TC, Cedernaes J, Rosqvist F, Benedict C. Association of Daily Eating Duration and Day-To-Day Variability in the Timing of Eating With Fatal Cancer Risk in Older Men. Front Nutr. 2022 May 10;9:889926. doi: 10.3389/fnut.2022.889926. PMID: 35619965; PMCID: PMC9127957.Links and references of interest:Study evaluating the effect of late dinner on breast and prostate cancer risk Chemotherapy and timing of fasting, University of Southern California studyChemotherapy patients who fast report fewer side effects. Longo group, 2009UCSF fasting page has been taken down. Here is one from City of Hope Cancer Center, in southern California/ greater Los Angeles areaFasting cycles retard growth of tumors and sensitize a range of cancer cell types to chemotherapy. Sci Transl Med. Longo group, 2012 PMID: 22323820Dawn Lemanne, MD Oregon Integrative OncologyLeave no stone unturned.Deborah Gordon, MDNorthwest Wellness and Memory CenterBuilding Healthy Brains
Dr. Shannon Westin and Dr. Mustafa Raoof discuss the paper "Medicare Advantage: A Disadvantage for Complex Cancer Surgery Patients" TRANSCRIPT Dr. Shannon Westin: Well, hello, everyone, and welcome back to another episode of the JCO After Hours podcast, where we get in-depth on articles that have been published in the JCO. I am your host Shannon Westin, and it is my pleasure to serve as the Social Media Editor for the Journal of Clinical Oncology, as well as a Professor in GYN Oncology at The MD Anderson Cancer Center in Houston. And today, I am very excited to be discussing a paper that was recently published in the JCO called “Medicare Advantage: A Disadvantage for Complex Cancer Surgery Patients.” And I am accompanied today by Dr. Mustafa Raoof, and he has no conflicts of interest to disclose. He is an Assistant Professor in the division of Surgical Oncology, Department of Surgery, and an Assistant Professor in the Department of Cancer Genetics and Epigenetics at the City of Hope Cancer Center. And there, he is a Surgical Oncologist with expertise in hepatobiliary and pancreatic cancer, and I'm thrilled to have him here today. Welcome, Dr. Raoof. Dr. Mustafa Raoof: Thank you. It's a pleasure to be here. Thank you for inviting me. Dr. Shannon Westin: Of course. And thank you for your incredible work. We're going to get right to it. This is, I think, a really timely and important paper because I think we are always trying to understand how the insurance coverage or the medical coverage that our patients have here in the United States impacts their overall quality of care. So, first, let's level set for the audience. Can you describe the basics of Medicare Advantage, which is what you explored in this paper, and how common is this coverage in the United States? Dr. Mustafa Raoof: So, Medicare Advantage is the privatized aspect of Medicare, and what we know is that since the 1970s there were some private plans that were part of Medicare. But really at the turn of the century, 2000 and onwards, Medicare Advantage has gained a lot of popularity. And this is where the government basically pays a lump sum cost for a beneficiary to private insurance companies to manage Medicare. And so, it's a privatized product. And the idea there is that it's supposed to be an all-encompassing product for the beneficiaries, and the biggest advantage, initially at least, was that there was an out-of-pocket maximum, so patients are not subjected to extreme financial stresses. The cost that was paid to Medicare Advantage plans per beneficiary were in the order of somewhere between 800 and $900 per beneficiary, per year. This was a little bit higher than what would have been the cost to Medicare, but that was to gain a lot of momentum into getting the private insurance interested in the plan. And then subsequently into that, there were a lot of incentives that were set for these Medicare Advantage plans based on some measures of quality, to kind of incentivize the quality products from this private insurance. And so, that's kind of the lay of the land for what the Medicare Advantage plans are. Now, in terms of, how popular are they? I think this has grown significantly over the last 10 years, especially, 46% of all Medicare beneficiaries nationally are part of this Medicare Advantage plan, and it's not one plan, every private insurance company has their own offerings. But a significant majority, I think it's estimated that more than half, and even, you know, going beyond 10 years, the majority of Americans will be insured by these Medicare Advantage plans. Dr. Shannon Westin: That's incredible, and certainly, that means this work that you did has such great impact with the number of patients that are going to be impacted. Can you give the listeners a little bit of an idea of how Medicare Advantage coverage might differ a little bit from the traditional? I know you mentioned the out-of-pocket costs, and that it's run by different companies, but any other kind of discerning features? Dr. Mustafa Raoof: Yeah. So, with the Medicare Advantage plans, as I mentioned, you know, there's an out-of-pocket maximum. In addition, vision and dental plans, as well as gym memberships are included as part of the plan, to kind of provide a holistic plan to the older Americans. And then, one of the things that kind of stands out is that what is the downside to Medicare Advantage plans from a company that is providing this kind of a product, and so, they have to cut costs somewhere. So, I think the main downside to patients would be that their options, in terms of specialist care, will be limited because the networks are generally narrower. There is a variability in different plans as to how big and small their networks are, but they could be more restrictive, and if a potential beneficiary is not aware of that, they could lose out on seeing some doctors that they would've otherwise wanted to see. Dr. Shannon Westin: Okay. That totally makes sense. And so, I guess the next natural question is, what led you to explore the impact of this coverage Medicare Advantage on patient outcomes in surgical practice? Dr. Mustafa Raoof: Yeah. So, as somebody who sees patients with advanced cancer, I think a lot of Medicare Advantage beneficiaries are caught by surprise at the time when they're seeking out care, and they think that they have Medicare, and they should be able to seek whatever care that they would like. Whereas, you know, when they contact their provider, they're told that they have to go to a certain doctor in a certain network. And the shock that this is, as a secondary shock, in addition to the shock of a cancer diagnosis and needing a surgical intervention. So, early on in my training, I had seen some of that, and, you know, I really wanted to delve deeper into helper based problems, is: does it even matter if they go with different specialists, as long as there is some quality to that? And so, I started looking into the quality of the Medicare Advantage network from there on. Dr. Shannon Westin: That leads us directly into your study. Why don't you give us a rundown of the design, and how you wanted to achieve those objectives that you just discussed? Dr. Mustafa Raoof: So, leading up to the study, we had a publication in Annals of Surgery that looked at what do the networks look like for these Medicare Advantage plans. And that kind of information is hard to find. As you could tell, a lot of patients don't even know if a certain hospital will be covered by their insurance. And so, through a collaboration with Gretchen Jacobsen who studies this as well, they had compiled data on the networks for different hospitals, and for different plans in LA County, as to which hospitals were covered. So, we looked at that, and we found that a lot of these Medicare Advantage plans don't have access to high-volume hospitals, which was our way of measuring quality. And so, that kind of set the tone for this, and then we wanted to ask if there is a difference in outcome between patients who are insured by Medicare Advantage versus those who are insured by traditional Medicare. Medicare Advantage data has been a little bit tricky to obtain for a lot of folks that I think it wasn't released because of data quality issues. We were a little bit lucky, in that we had access to the California Cancer Registry dataset, which includes all patients diagnosed with cancer in California, and that data was linked to discharge data from inpatient hospitalizations. And so, one of the categories that is collected is patients' insurance, whether it's Medicare or not, and whether it's managed or not. So, with that, we thought it was the perfect opportunity to ask a very simple question, and that question is, what are the differences in terms of access to high-volume surgery or quality cancer surgery, and what are the impacts on the outcome for the two different kinds of insurance plans? So, the design is a retrospective cohort analysis, and we included all patients who were undergoing elective inpatient cancer surgery. We selected some index cancers, and we realized that it's not comprehensive, but we wanted to give it a go with some of the more common cancer diagnoses. So, we included lung, colon, and rectal, and then we also included some high complexity operations such as esophagus, stomach, pancreas, and liver, and we included all data from 2000 to 2020. And in terms of the primary objective of the study, we wanted to look at hospital mortality, so we looked at the association between 30-day hospital mortality, but we also looked at complications, readmissions, and failure to rescue. One of the other objectives of this study was to look at the association between insurance stipend, access to care-- we defined access to care in several different ways. Because there's no singular definition, we said access to care would be somebody getting access to cancer surgery at a Commission on Cancer-designated hospital, or NCI-designated cancer center, or a high-volume hospital, as defined by other authors previously, or a teaching hospital. So, we used several different definitions to kind of see if there is association between insurance and patients' access to care. Dr. Shannon Westin: And let's hear it. What were the results? How did Medicare Advantage compare to traditional Medicare? Dr. Mustafa Raoof: Given our previous work on MA networks data, this was not a surprise, but when we saw that for all of the cancers that we looked at, there were significant barriers to access, in terms of getting to an NCI-designated cancer center, or a high-volume cancer center. So, no matter how we looked at it, we felt that there was a significant disparity in getting to these specialist hospitals, which we associate with quality of cancer surgery. But what was interesting in a major finding of the paper was that for certain cancers, for example, gastrectomy, pancreatectomy, and hepatectomy, we found significantly increased early-day mortality for those operations. And so, for example, for gastrectomy, there was 1.4-fold higher mortality, for pancreatectomy 1.9-fold, and then for hepatectomy, 1.4-fold. So, these are tangible figures in-- you know, the idea is that if somehow we can improve access to high-quality surgery within MA plans, to match that of traditional Medicare, which is not ideal still, but I think just by doing that, we could impact, potentially reduce cancer deaths from surgery itself. Dr. Shannon Westin: So, I was struck by the fact that there was a difference between the outcomes you mentioned - stomach, pancreatic, liver surgery, and colon cancer. You know, why do you think there might be a difference? Dr. Mustafa Raoof: That's a great question. So, I think colon cancer surgery has-- I wouldn't say it is low-complexity, but it's intermediate-complexity. And I think as a surgical workforce, a lot of surgeons who may or may not be trained with fellowship specialization, they are able to do a really good job of colon resection, and so, there are many high-volume surgeons that do not actually sit in NCI-designated cancer centers or CoC-accredited hospitals, and they're doing a really good job. And so, I think we see that the impact of access is less in colon surgery, and I think that may explain why that is. Dr. Shannon Westin: We've looked at this, and I know you said that you picked some common cancers, and I know you did that because, you know, I'm a GYN Oncologist, so I was definitely interested in outcomes here. We definitely see that, in especially ovarian cancer surgery, which is rare, is that high-volume centers matter. And it can be a comprehensive cancer center, or it can just be a really high-volume center that draws a lot of ovarian cancer, it doesn't necessarily have to be a cancer center. So, that certainly makes a lot of sense. I guess the next question really is what happens next for this work? Like, what can we do to make a difference here? Dr. Mustafa Raoof: So, just reading the landscape on health insurance, I think there's significant incentives for Medicare Advantage plans. So, I think that is going to exist, and I think that will be in the future. I think the important aspect will be to ensure the quality of Medicare Advantage plans. And I think the data that is presented in this study, we hope that it will shed some light, and give a voice to patients who are dealing with a situation where they need complex cancer surgery. And we also hope that there would be some transparency when patients are signing up for the insurance plans, they should be able to say, "Okay, well, with the Medicare Advantage plan, we are getting this quality of cardiac care, this quality of cancer surgical care", and I think that should be an important component. You know, some Medicare Advantage plans may excel in one aspect of care, for example, you know, Alzheimer's care or cardiac care, but may do poorly in cancer surgery care, or cancer care in general. So, I think those are some of the things that the policymakers will need to balance and incentivize. Medicare Advantage plans are really great at cutting utilization because they manage healthcare effectively, but it does introduce some sort of inefficiencies in the system where everything requires a prior authorization; a lot of physicians are familiar with that - a patient needs life-saving surgery, and the authorization is nowhere to be found for two, three weeks, four weeks, and that's a really difficult problem for the patient to go through, and their caregivers. It's a difficult time for them. So, I think those inefficiencies can be mitigated as long as those who require cancer surgery are seen as a distinct population who need timely access to high-volume surgery. I think modifying MA plans in a better way to reflect that, will be the future. Dr. Shannon Westin: Yeah. We've seen this come up on the podcast multiple times as we're talking about inequities and quality of care. You know, it's on us as physicians and practitioners to interact with our policymakers. We've not always been really good at that, but I think this type of work that you've done really helps us have that objective data that we can bring to these policymakers so this change can be enacted. Well, thank you so much, Dr. Raoof. We really appreciate you taking the time being on the podcast. And again, for our listeners, this was a discussion of “Medicare Advantage: A Disadvantage for Complex Cancer Surgery Patients,” and we were with the first author, Dr. Mustafa Raoof. Please make sure you check it out, and please feel free to check out our other podcasts on the JCO website. Until next time, this has been Shannon Westin, with JCO After Hours. Have a great day. 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.
In this episode of Lung Cancer Considered, hosts Dr. Narjust Duma and Dr. Stephen Liu discuss the recently completed ASCO meeting with colleagues Dr. Catherine Shu and Dr. Jack West. Dr. Shu is a board-certified medical oncologist specializing in the treatment of thoracic cancers, especially lung cancer, at Columbia University's Herbert Irving Comprehensive Cancer Center. Dr. West is a medical oncologist at City of Hope Cancer Center and is the founder of the Global Resource for Advancing Cancer Education, a nonprofit organization dedicated to providing timely, free, credible information to patients and caregivers around the world.
In this episode, I'm talking to Dr. Rahul Jandial, a brain surgeon & neuroscientist at The City of Hope Cancer Center. We discuss our current climate of stress, resiliency, and constant stimulation; how that affects our brains, how to properly multi-task and unplug, and how to train your brain to cope. We also discuss brain health; what little things you can do each day to improve your brain's well-being and how to access the brain's natural Valium. www.Athleticgreens.com/blondefiles for a free 1 year supply of vitamin D and 5 free travel packs with your first purchase. www.Arrae.com with code 'blondefiles' for 10% off one-time purchases or 25% off first month of subscription. www.Sakara.com/Blondefiles20 for 20% off your first order. www.Foriawellness.com/Blonde for 20% off your first order. Produced by Dear Media
Adjuvant immunotherapy is a game-changer for early lung cancer, but it is not the best choice for every patient. Through patient cases, Drs. Karen Kelly (University of California Davis) and Howard West (City of Hope Cancer Center) explore considerations in shared decision making and personalizing therapy. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: education.asco.org | Contact Us Air Date: 12/15/21
https://www.linkedin.com/in/leetomlinson/ (Lee Tomlinson) had a life many would have considered charmed. A successful world-trotting tennis pro, international businessman, marketing genius behind the American Film Institute's 10-year long 100 Greatest Movies CBS TV specials and multi-million-dollar fundraising campaign, major Hollywood film studio owner, loving husband, and near scratch golfer. Until the world crashed down, and he was subsequently diagnosed with Stage III+ throat cancer, and subjected to months of life-threatening, debilitating chemo and radiation, and extreme pain--so extreme he could not eat or even swallow. Towards the end of his grueling treatment, while hospitalized for a severe infection, a never-ending stream of insensitive, unkind acts totally lacking in compassion by the hospital staff, sent Lee into an abyss of emotional despair that made him choose suicide over life. Fortunately, another doctor, a dear friend, stopped him by deeply apologizing on behalf of a healthcare system that had failed to provide him-and so many others, with even a hint of compassion. And with one simple suggestion--inspired Lee to use his gifts as a speaker, customer service expert and leader to restore compassion to healthcare--not only for patients, but also for all the overworked, under-supported, burned-out healthcare professionals who've literally lost the ability to provide the compassion that got them into medicine in the first place. Lee's powerful crusade is documented in his new book https://www.amazon.com/Compassion-Heals-Healthcare-Lee-Tomlinson-ebook/dp/B091Y4W471 (Compassion Heals: From Self-Care to Healthcare). But there is a message here for more than healthcare professionals (HCPs). There's a message for all of us about the power of compassion to heal others' mental, emotional and physical pain - but to also love and heal ourselves - and in doing so, help heal the world at a critical time in our history. Lee's book presents the evidence that compassion heals by sighting numerous scientific studies, books and resources. But the most telling statistic he cites is that more than 50% of Americans believe that healthcare and healthcare professionals totally lack compassion. Data shows that people die because of compassionless care, not just from medical errors. Compassionless healthcare has become more the norm over the past 25 years. Left unchecked, the future of healthcare is unthinkable. And that's why Lee is driven to make a difference. He has taken to the stage as "Patient Lee" dressed in nothing but a hospital gown, and presented his mixture of humor, compassion, urgency, encouragement and call-to-action at more than 200 venues, including keynote presentations to Johns Hopkins Medicine, Memorial Sloan Kettering, UCLA Medical Center, Eli Lilly & Co., Providence Health & Services, David Geffen School of Medicine, Bristol Myers Squibb, Siemens Medical Imaging, City of Hope Cancer Center, Adventist Health, and national conferences for the Oncology Nurse Society (ONS), Academy of Oncology Nurses and Patient Navigators (AONN), Association of Integrated Health and Medicine (AIHM) and Hematology/Oncology Pharmacy Association (HOPA). The problem, as Lee discovered when speaking with members of his audiences, is that HCPs are totally spent themselves, bereft of energy and emotional sustenance. More than 60 percent of them are suffering from burnout and, as such have zero compassion to give anyone because they're not given themselves enough to stay healthy and able to do so. So much of Compassion Heals is a recipe for self-care. Ways that healthcare workers can step off the treadmill and restore themselves, so they can freely give from a well of wellbeing and compassion within. Far from being punitive, Compassion Heals is in itself a healing balm. Filled with understanding and kindness for those who are falling short, along with those who are in their hands, this book
Over the last several years, a handful of states have passed legislation authorizing physicians to provide medical aid in dying for terminally ill adults. This typically comes in the form of a prescription to relieve discomfort and promote a peaceful death. According to our guest today, medical aid in dying should not only be legal everywhere, but this compassionate option should be made more accessible. For example, Dr. Chandana Banerjee, a palliative care specialist at the City of Hope Cancer Center, says that extended waiting periods before patients can avail themselves of this option should be eliminated. Dr. Banerjee also discusses her poetry books in today's episode!
Compassion Heals: From Self-Care to Healthcare By LeesTomlinson "Patient" Lee Tomlinson, the Compassionate Care Crusader, On a Mission to Restore Compassion to Healthcare, Healthcare Professionals and the World at Large! Lee Tomlinson had a life many would have considered charmed. A successful world-trotting tennis pro, international businessman, marketing genius behind the American Film Institute's 10-year long 100 Greatest Movies CBS TV specials and multi-million-dollar fundraising campaign, major Hollywood film studio owner, loving husband and near scratch golfer. Until the world crashed down, and he was subsequently diagnosed with Stage III+ throat cancer, and subjected to months of life-threatening, debilitating chemo and radiation, and extreme pain--so extreme he could not eat or even swallow. Towards the end of his grueling treatment, while hospitalized for a severe infection, a never-ending stream of insensitive, unkind acts totally lacking in compassion by the hospital staff, sent Lee into an abyss of emotional despair that made him choose suicide over life. Fortunately, another doctor, a dear friend, stopped him by deeply apologizing on behalf of a healthcare system that had failed to provide him-and so many others, with even a hint of compassion. And with one simple suggestion--inspired Lee to use his gifts as a speaker, customer service expert and leader to restore compassion to healthcare--not only for patients, but also for all the overworked, under-supported, burned-out healthcare professionals who've literally lost the ability to provide the compassion that got them into medicine in the first place. Lee's powerful crusade is documented in his new book Compassion Heals: From Self-Care to Healthcare. But there is a message here for more than healthcare professionals (HCPs). There's a message for all of us about the power of compassion to heal others' mental, emotional and physical pain - but to also love and heal ourselves - and in doing so, help heal the world at a critical time in our history. Lee's book presents the evidence that compassion heals by sighting numerous scientific studies, books and resources. But the most telling statistic he cites is that more than 50% of Americans believe that healthcare and healthcare professionals totally lack compassion. Data shows that people die because of compassionless care, not just from medical errors. Compassionless healthcare has become more the norm over the past 25 years. Left unchecked, the future of healthcare is unthinkable. And that's why Lee is driven to make a difference. He has taken to the stage as "Patient Lee" dressed in nothing but a hospital gown, and presented his mixture of humor, compassion, urgency, encouragement and call-to-action at more than 200 venues, including keynote presentations to Johns Hopkins Medicine, Memorial Sloan Kettering, UCLA Medical Center, Eli Lilly & Co., Providence Health & Services, David Geffen School of Medicine, Bristol Myers Squibb, Siemens Medical Imaging, City of Hope Cancer Center, Adventist Health, and national conferences for the Oncology Nurse Society (ONS), Academy of Oncology Nurses and Patient Navigators (AONN), Association of Integrated Health and Medicine (AIHM) and Hematology/Oncology Pharmacy Association (HOPA). The problem, as Lee discovered when speaking with members of his audiences, is that HCPs are totally spent themselves, bereft of energy and emotional sustenance. More than 60 percent of them are suffering from burnout and, as such have zero compassion to give anyone because they're not given themselves enough to stay healthy and able to do so. So much of Compassion Heals is a recipe for self-care. Ways that healthcare workers can step off the treadmill and restore themselves, so they can freely give from a well of wellbeing and compassion within.
In this CTSNet To Go podcast episode, Mara Antonoff moderates a roundtable on the role of metastasectomy in pulmonary metastatic disease. She is joined by Erin M. Corsini of MD Anderson Cancer Center, Loretta Erhunmwunsee of City of Hope Cancer Center in California, and Neel Chudgar of Memorial Sloan Kettering Cancer Center in New York. They discuss variability in practice patterns, specific tumor types, and patient selection.
An interview with Dr. Jessica Hwang from MD Anderson Cancer Center and Dr. Andrew Artz from City of Hope Cancer Center on “Hepatitis B Virus Screening and Management for Patients with Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update.” This update presents a clinically pragmatic approach to HBV screening and management that calls for universal HBV serological testing of patients at the onset of anticancer therapy. Read the full PCO at www.asco.org/supportive-care-guidelines Transcript 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. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. 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 podcast.asco.org. My name is Brittany Harvey. And today, I'm interviewing Dr. Jessica Hwang from the University of Texas M.D. Anderson Cancer Center in Houston, Texas, and Dr. Andrew Artz from the City of Hope Comprehensive Cancer Center in Duarte, California, co-chairs on hepatitis B screening and management for patients with cancer prior to therapy, ASCO provisional clinical opinion update. Thank you for being here, Dr. Hwang and Dr. Artz. Thank you for inviting us. Thank you so much. First, I'd like to note that ASCO takes great care in the development of its guideline products and ensuring that the ASCO conflict of interest policy is followed. The full conflict of interest information for this provisional clinical opinion panel is available online with the publication in the Journal of Clinical Oncology. Dr. Hwang, do you have any relevant disclosures that are related to this topic? Well, I have received some research funding from Gilead, a maker of a hepatitis drug in the past. And, Dr. Artz, do you have any relevant disclosures? I have no relevant disclosures. OK, then so, Dr. Artz, so this provisional clinical opinion, or PCO, on hepatitis B screening and management for patients with cancer prior to therapy was first published in 2010 and then last updated in 2015. What prompted this update to the PCO? This PCO guidance, more broadly, is necessary because the hepatitis B status for most patients is actually unknown at the time they're starting cancer therapy. In 2015, the PCO though suggested that we limit hepatitis B screening to patients who were at most risk for hepatitis B reactivation, if they were hepatitis B carriers, so those receiving anti-CD20 antibodies, such as rituximab or stem cell transplant. But for the remaining patients, most patients receiving cancer therapy, the guidance was to survey patients about their close contacts or exposures to hepatitis B and determine if formal hepatitis testing should ensue. This 2020 PCO represents an evolution in our understanding of hepatitis B screening and the dangers of hepatitis B after anticancer therapy. We've learned from studies, including those done by my colleague, Dr. Hwang, that questionnaires to detect hepatitis B are not very effective or practical. We also have accumulating information that many of our anticancer therapies pose a significant danger for hepatitis B related complications in hepatitis B infected patients. We believe appropriate monitoring and treatment, as outlined in the PCO, will reduce these dangers. So given that new information, I'd like to discuss the updated statements for the PCO. So first, Dr. Hwang, for patients who will receive systemic anticancer therapy, who should be tested for HBV and how should they be tested? That's a great question, Brittany. Thanks. I think that the data is really clear now that all patients with cancer anticipating systemic anticancer therapy should be tested for hepatitis B virus. That includes all solid tumor patients, as well as hematologic malignancy patients. And they can be tested with a simple blood test. The hepatitis B virus can be tested by three blood tests for hepatitis. It's the hepatitis B surface antigen, HBsAG, or the hepatitis B core antibody. There are two types of this. It's either the IgG or the total IG, which shows, if positive, could indicate a patient has past infection. There is a IgM version of that core antibody test. And that tells, if positive, tells whether a patient has acute infection. So for our purposes, it's recommended that the IgG or total IG is used and not the IgM, because we are interested in whether a patient has past infection. So the third test is a hepatitis B surface antibody. And this is a protective antibody. So if positive, it shows that a patient has had some exposure in the past or perhaps a vaccination in the past. And so this is a good test to have positive. So then what does the PCO state for patients with chronic HBV infection? Patients with chronic HBV infection, that is those patients with a positive hepatitis B surface antigen test, these patients really should have very close monitoring during as well as after anticancer therapy. These patients will need antiviral therapy prophylactically prior to enduring as well as after the cancer treatment. They should also see a clinician experienced in the management of hepatitis B, whether it's a hepatologist, a gastroenterologist, an infectious disease specialist, or maybe a primary care doctor who's experienced in treating and caring and monitoring for patients with hepatitis B. That's really important for these patients with a chronic hepatitis B, because they are at high risk of developing complications during and as well as perhaps even shortly thereafter of receiving systemic anticancer therapy. And then what does the PCO state for patients with past HBV infection? This is a really good question. The patients with past HBV infection are those who have a negative hepatitis B surface antigen and a positive hepatitis B core antibody. This represents maybe some 6% at least of the US population. It could be much higher. So this is a sizable group of patients. And it's really important to know that it is sort of a tailored approach. So patients with past HBV infection who are anticipated to receive one of the high risk anticancer therapies that Dr. Artz mentioned just a few moments ago, namely stem cell transplantation or maybe one of the anti-CD20 monoclonal antibodies, these patients are at really high risk of reactivation. So these patients would need a very close monitoring plan. They would need their hepatitis B and liver test monitored during their anticancer therapy. And most often they would need antiviral prophylaxis before, during, and even after their immunosuppressive therapy ends. So there are patients, of course, who don't receive these high-risk therapies. So that is patients with past HBV infection who are receiving anticancer therapy that's not a stem cell transplant and not an anti-CD20 monoclonal antibody. These patients could be monitored carefully. They could have hepatitis B and/or liver testing monitoring during anticancer therapy. And if they have any elevations in their surface antigen or their ALT, then they could have further hepatitis B testing to see if they have any evidence of complications from their hepatitis B. So that's in general what the PCO recommends for these two groups. Well, thank you for reviewing those highlights from the PCO. So Dr. Artz, what is the importance of this PCO and how will its implementation impact practice? Thank you for the question. This PCO I feel dramatically simplifies the challenge of hepatitis B screening by proposing universal hepatitis B testing, as Dr. Hwang outlined, at a defined point in time. That is at the initiation of therapy. And clinicians have really struggled with hepatitis B testing for lots of different reasons. They're difficulties in knowing who to screen, how to screen, in part because the data have started to emerge that many of the therapies may pose some risks and the prior suggestion that we use questionnaires, but there wasn't a standard set of questionnaires that we could use if we wanted to identify people based on risk factors of acquiring hepatitis B. So this led to a lot of confusion on testing. I think by standardizing this makes it considerably easier. And also, the guidance from the PCO is better harmonized with other organizations, such as the Centers for Disease Control and our Liver Society colleagues who actually participated in the panel. And so now the guidance clinicians receive are more consistent across organizations. So I think this will allow doctors and health care systems overall to now invest in the implementation of hepatitis B screening, rather than the question about who should we do it and can we do it and when should we do it, but rather more on the implementation to help patients. Great. And then finally, what is the impact of this updated PCO for patients? Well, I'll take the first part of that. I believe that the implementation should permit safer systemic anticancer therapy by reducing hepatitis B related complications. Whenever patients have complications or there's even uncertainty about whether hepatitis might be contributing, this also can lead to delays in our treatments. If we know in advance and we appropriately manage and monitor this, we should have fewer treatment delays as well. Dr. Hwang, I know, might also have some comments on this. Thanks. I do have a few general comments beyond the cancer care implications. And I'd like to say I think that hepatitis B testing and then the results of that and sharing that information with patients is really important. Letting patients know their hepatitis B status, especially if they're positive, empowers them to seek further care, get connected with a hepatitis B specialist person who's experienced in managing hepatitis B, and also to look around the local environment to their household and close contacts because hepatitis B is a virus that is transmitted from person to person through blood-borne sexual transmission and close family or household contact. So I think it's important for patients to know their status to protect themselves during cancer therapy, as Dr. Artz mentioned, but just in general for good health care for themselves and for those around them. And in addition, I think that it's important for the family members and those close contacts to then get screened and perhaps even consider getting vaccinated if they haven't been vaccinated. Well, thank you both for your hard work on updating this PTO and for taking the time to speak with me today, Dr. Hwang and Dr. Artz. Thank you, Brittany. Thank you, Brittany. And thank you to all of our listeners for tuning into the ASCO Guidelines podcast series. To read the full provisional clinical opinion go to www.asco.org/supportive-care-guidelines. This PCO also has a companion cancer.net podcast episode. Cancer.net is the patient information website of ASCO. And we encourage you to learn more by tuning into their episode. You can find their podcast and all ASCO podcasts at podcast.asco.org. You can also find many of our guidelines, PCOs, 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.
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 world’s leading professional organization for doctors who care for people with cancer. 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. 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 clinical trials described here may no longer be enrolling patients, and final results are not yet available. Before any new cancer treatment can be approved for general use, it must be studied in a clinical trial in order to prove it is safe and effective. In today’s podcast, members of the Cancer.Net Editorial Board discuss 3 clinical trials that are exploring new treatment options across prostate, bladder, and kidney cancer. This podcast will be led by Dr. Timothy Gilligan, Dr. Sumanta (Monty) Pal, Dr. Petros Grivas, and Dr. Tian Zhang. Dr. Gilligan is an Associate Professor and Medical Oncologist at the Cleveland Clinic Taussig Cancer Center. He has no relevant relationships to disclose. Dr. Pal is co-director of City of Hope's Kidney Cancer Program and is the head of the kidney and bladder cancer disease team at the institution. He has served in a consulting or advisory role for Astellas Pharma, Exelixis, and Pfizer. 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. He has served in a consulting or advisory role for Exelixis, Merck, and Pfizer. Dr. Zhang is an assistant professor of medicine at Duke University School of Medicine and is a medical oncologist at Duke Cancer Institute. She has served in a consulting or advisory role for Exelixis, Merck, and Pfizer. View full disclosures for Dr. Gilligan, Dr. Pal, Dr. Grivas, and Dr. Zhang at Cancer.Net. Dr. Gilligan: Hi. I'm Dr. Timothy Gilligan from the Cleveland Clinic. I'm joined today by Dr. Monty Pal from the City of Hope Cancer Center, Dr. Petros Grivas from the Fred Hutchinson Cancer Research Center and University of Washington, and Dr. Tian Zhang from Duke Cancer Institute. Today, we're going to discuss three ongoing clinical trials in prostate, bladder, and kidney cancer. As you may know, clinical trials are the main way the doctors are able to find better treatment for cancer and other diseases. Patient participation is vital for clinical trials. By participating in a clinical trial, you can directly help researchers develop better treatment, reduce side effects, or even reduce the risk of cancer all together. The three trials we'll discuss today were chosen by members of the Cancer.Net Editorial Board Genitourinary Cancers Panel from the trials and progress abstracts that were presented at ASCO's 2020 Genitourinary Cancers Symposium. Because these are ongoing clinical trials, final results from these studies are not available yet. I'd like to note that none of us have any direct involvement with any of these trials. To view our full disclosures, please visit the show notes for this episode on Cancer.Net. So to get started, the first study we'll discuss is the TALAPRO-2 trial for prostate cancer, [Talazoparib + Enzalutamide vs. Enzalutamide Monotherapy in mCRPC (TALAPRO-2)] and Dr. Pal is going to discuss this. So if we could get started, just to begin with, who is the study designed for? Dr. Pal: Thanks a lot, Dr. Gilligan. Well, this study addresses a unique disease population. It's patients with prostate cancer that's metastatic, and that implies that the cancer has migrated out of the prostate to other organs. But beyond that, it also implies that these patients have also developed some resistance to first line hormone treatment. So patients in this study [have] so-called hormone resistant or castration resistant [prostate cancer]. Dr. Gilligan: So if a patient was in this situation, and they weren't going on this trial, what would be the standard treatment for them at this time? Dr. Pal: There are several options for these patients. Hormone therapies like abiraterone and enzalutamide could be considered. Chemotherapy is also a consideration. Dr. Gilligan: And can you say a little bit more about what the patients would receive if they went on it? The subjects of the study, what they'll get? Dr. Pal: Some patients with prostate cancer may have [a deficiency in their cancer’s ability to repair damage to DNA]. This is something that we've seen in other tumor types, breast cancer perhaps being the most notable example. Pancreatic cancer being another one. In this particular trial, [the researchers] try to exploit that by using a class of drugs called PARP inhibitors. In this case, a drug called talazoparib. So patients in this study receive a standard hormone therapy called enzalutamide. And they receive that with or without this drug, talazoparib. Dr. Gilligan: So they will get either-- what you described before is the standard of care—hormonal therapy, or that combined with this new drug. Dr. Pal: That's exactly right, Dr. Gilligan. Dr. Gilligan: I wanted to make that clear because this is a trial that has placebo, and sometimes research [participants] have concern about, "Do I want to be on a trial that has a placebo?" Do you want to say anything about that? Dr. Pal: It's very important to bear in mind that every patient that enrolls in this study is going to get the standard treatment in this setting. As I've mentioned before, enzalutamide represents one of those options. And, of course, in this trial above and beyond that, they have the possibility of getting talazoparib or a placebo. So certainly patients won't be receiving placebo alone in this trial. Dr. Gilligan: Do you want to say anything more about what's kind of interesting about this new approach to treating prostate cancer? Dr. Pal: What I think is quite inventive about this study is that talazoparib, the PARP inhibitor, is being combined with hormone therapy. And I think that's the real difference in what this protocol offers versus the treatment strategies that now represent a standard option for patients. Dr. Gilligan: Right. And my understanding is that the hope is that by using this combination, we'll be able to make treatment more effective. Dr. Pal: Absolutely. When we talk about PARP inhibitors and prostate cancer currently, we're typically restricting it to patients who have these so-called DNA damage repair mutations. And that's certainly a finite group of individuals. In this particular trial, we're actually going to look not just at those patients, but all patients within this disease state. So we go beyond the 25 to 30 percent of patients who are estimated to have alterations in DNA damage repair. Dr. Gilligan: Right. I think that's an important point: to get on this trial, patients don't have to have a particular genetic profile. So how will success be evaluated? How will we know if it's working? Dr. Pal: In this case, we're going to be looking at the delay in cancer growth as the primary outcome measure. We're certainly hoping that the combination of enzalutamide with talazoparib is going to slow growth relative to enzalutamide plus placebo. The innovative endpoint that's explored in this study is also diving deeper and looking at those patients who have these DNA damage repair mutations that's going to also reflect one of the primary outcome measures in this study. And that's something quite important to bear in mind. Dr. Gilligan: So we have some experience with PARP inhibitors. Can you say something about what we know about the side effects? Dr. Pal: Fatigue is a relatively common side effect. Decreases in blood counts is another potential side effect. And in particular in my clinical experience, I've seen drops in the white blood cell counts. That of course makes patients more susceptible to infection. Diarrhea may also be one of the consequences within this class of drugs. And certainly, I would refer patients to a more comprehensive discussion of these side effects with their clinicians before entering into the study. Dr. Gilligan: Is the trial still accruing patients? And do we know when we might expect results? Dr. Pal: I think that there are many trials within this particular space. This one is ambitious in that it hopes to accrue over a thousand patients. I don't have a good finger on the pulse of when results will report. But I'm sure that'll be the subject of future podcasts for us. Dr. Gilligan: Well, thank you very much Dr. Pal. It's a very exciting study and exciting new area of research in prostate cancer. Dr. Pal: Definitely. Dr. Gilligan: We're going to move on now to the second study we want to talk about, which is the KEYNOTE-905 study. [Perioperative Pembrolizumab (MK-3475) Plus Cystectomy or Perioperative Pembrolizumab Plus Enfortumab Vedotin Plus Cystectomy Versus Cystectomy Alone in Cisplatin-ineligible Participants With Muscle-invasive Bladder Cancer (MK-3475-905/KEYNOTE-905/EV-303)] And Dr. Grivas is going to talk to us about that. Can you orient us, Dr. Grivas, to what this study is, for which group of patients, and what it's looking at? Dr. Grivas: This clinical trial is applicable to patients with localized, meaning not spread, bladder cancer. And when the bladder cancer has invaded the muscle layer of the bladder, we call this muscle invasive bladder cancer. And these patients usually go for cystectomy, the removal of the bladder. And ideally, they get chemotherapy before, but some patients may not be fit enough for chemotherapy. So those patients go straight to cystectomy, the removal of the bladder. So this clinical trial is trying to evaluate whether immunotherapy with this drug, called pembrolizumab, helps these patients before they get the cystectomy. Dr. Gilligan: Can you tell us a little bit more about pembrolizumab and what we know about it? Where it's used currently in bladder cancer? Dr. Grivas: Pembrolizumab has three different indications for patients with bladder cancer. The first one is in an earlier stage, what we call non-muscle invasive bladder cancer, which is a very superficial cancer, when the cancer is not invading through the muscle layer. And there's a specific indication for those patients who get therapy with BCG, which is a form of immunotherapy given inside the bladder. And if the cancer is not responding well to this BCG, usually, they go for removal of the bladder. But some of them may not be able to do that or do not want that. And pembrolizumab has a track record in those specific scenarios of BCG-unresponsive tumors as we call them for those patients who cannot get cystectomy or don't want to have it. The other two indications are for patients who have metastatic, [meaning bladder cancer that has spread to other organs.] And there are two specific indications of pembrolizumab immunotherapy in that particular setting. So this trial is trying to expand upon the role of pembrolizumab in bladder cancer. Dr. Gilligan: So it's been shown to be a benefit when the disease is more advanced and now we want to see if it's helpful earlier on in the period of time around surgery. Dr. Grivas: Right. And it's interesting in a particular setting we're looking at this trial, because we have indications literally before and after in an earlier states, the non-muscle invasive disease setting. And also as you mentioned, Dr. Gilligan, in the more advanced setting. So we're trying now to see whether this middle setting of muscle invasive bladder cancer, whether there's a role of pembrolizumab by itself before removing the bladder. Dr. Gilligan: Are patients who are eligible to get chemotherapy prior to cystectomy able to go on this trial or is it only for patients who are not [well enough] to get chemotherapy? Dr. Grivas: This is for patients who are not in good condition to undergo chemotherapy. So if someone is in good condition to undergo chemotherapy, then the trial does not apply to them. This is only in those who cannot safely receive chemotherapy before the cystectomy. Dr. Gilligan: Thank you for clarifying that. What data do we have that makes us think that it may be a good idea to give immunotherapy prior to cystectomy? Because this has been looked at a little bit already, and I think it's why this trial is being done. Can you say a little bit about that? Dr. Grivas: Sure. I would like to underline that as you alluded before, the standard of care therapy for patients who undergo cystectomy, the removal of the bladder, is to undergo chemotherapy with a drug called cisplatin before cystectomy. But as we discussed before, this is the standard of care with a high evidence. However, many patients, maybe 50, maybe 55 percent of patients may not have enough condition to undergo this chemotherapy safely. And that is the population we would try to capture. And to answer your question, there have been so far, four clinical trials looking at immunotherapy before cystectomy. And all of those four clinical trials look very promising in that regard. So based on this promising information, this new trial the KEYNOTE-905 is a phase III trial trying to confirm the promising data from the previous phase II trials and help us make a final decision whether this should be the standard of care or not in patients who cannot undergo safely chemotherapy in that setting. Dr. Gilligan: What are the known side effects and risks of immunotherapy? Dr. Grivas: Immunotherapy overall is much better tolerated than chemotherapy. However, it can still cause significant side effects, especially in a small proportion of patients. So the main thing we need to keep an eye on is if the immune system gets too overstimulated, it can cause what we call immunotherapy-related adverse events or side effects. And any organ of the body could in theory be attacked by an overstimulated, overactive, immune system. So they are different forms of “-itis.” For example, if you have inflammation in the lungs, it's pneumonitis. In the liver, hepatitis. So we have to be careful and educate our patients, educate our medical providers and the teams, follow the patients and then report any new symptoms for changes in order to be able to recognize early and manage properly these side effects. As I mentioned, it's not common to have a severe reaction, but it can happen. So education helps, and I recommend to the patients to discuss with a medical provider the potential of those immunotherapy-related adverse events that usually, if they occur, can be managed with proper treatment to try to suppress, “cool down,” the immune system. So education is important. Dr. Gilligan: So just to summarize then, this is a trial for patients who would normally be treated with surgery alone, and we're looking at whether adding immunotherapy before and after surgery can improve those outcomes. Dr. Grivas: That's exactly right. Especially for those patients who cannot safely undergo chemotherapy before the surgery. Dr. Gilligan: And how are we going to measure whether it's successful? Whether that immunotherapy has improved outcomes or not? Dr. Grivas: The two measures that we're are looking at in this particular trial are the following. Number one, we tried to see how many patients--what is the proportion of patients from everybody who gets in the trial—who has no residual cancer cells at the time of the removal of the bladder, at the cystectomy. When the pathologist looks at the cystectomy sample in the lab after the bladder is removed from the body, what is the proportion of patients with no cancer inside the bladder after the immunotherapy compared to no immunotherapy at all? So we're going to compare these. We call this “complete response,” meaning no cancer is found in the bladder after its been removed, after the immunotherapy. And we're going to compare this complete response in the two groups. The other metric we use is to see how many patients have no recurrence regardless, meaning the cancer came back after the treatment. After the cystectomy, how many of those patients either had the cancer come back later or died from another cause. So we use these metrics and we compare the two metrics in the two populations in the trial with and without immunotherapy before the surgery. Dr. Gilligan: And currently, the relapse rate's roughly 50 percent, so we're hoping for a lower number than that. Dr. Grivas: Correct. We try to look for a lower number, and we try to see to compare these two populations with and without immunotherapy and see if immunotherapy adds value in that particular setting. Dr. Gilligan: Is this trial still open and do you know when we might see results from it? Dr. Grivas: The trial is open. It started recently, so I will strongly encourage the patients to discuss with their providers and look at particular locations where this trial is open. So definitely, there is room to go. And I think the trial will take a few years to complete and then report the results. So definitely an ongoing trial options for the patients. Dr. Gilligan: Great. Well, thank you very much. So an exciting trial for patients with localized bladder cancer going through surgery to see if we can improve outcomes, increase the cure rate, by adding this interesting new immunotherapy. Thank you, Dr. Grivas. Dr. Grivas: Thank you so much. Dr. Gilligan: So now we're going to move on and talk about the COSMIC-313 trial with Dr. Zhang from the Duke Cancer Institute. [Study of Cabozantinib in Combination With Nivolumab and Ipilimumab in Patients With Previously Untreated Advanced or Metastatic Renal Cell Carcinoma (COSMIC-313)] Can you tell us who this trial is designed for, or which group of patients? Dr. Zhang: Absolutely. We know that for patients with kidney cancer with a clear cell component and intermediate or poor risk by IMDC criteria, that both immunotherapy combinations with ipilimumab and nivolumab as well as the targeted therapy blocking blood vessel formation, called cabozantinib, have both demonstrated significant benefit for these patients. And these are approved treatments. So this particular trial is attempting to combine these starting as a triplet of ipilimumab, nivolumab, cabozantinib for four cycles and then maintenance nivolumab with cabozantinib. And this triplet treatment is compared to a placebo-controlled regimen of the same immunotherapies without the targeted therapy. Dr. Gilligan: So if a patient weren't going to go on this trial, what's the current standard of care? Dr. Zhang: Both the immunotherapy combination as well as having the cabozantinib by itself, are our standard of care therapies for these patients in these categories. Dr. Gilligan: Is this restricted to any particular group of kidney cancer patients? Dr. Zhang: These patients must have at least one of the IMDC criterion. So these are markers of inflammation, like high neutrophil count, low hemoglobin, or high platelet levels, high calcium levels, as well as poor performance status in less than one year from diagnosis to needing these type of treatments. Patients have to have kidney cancer that spread to other sites of their body or locally advanced disease which is not surgically resectable. And as a note, other treatments that are approved in patients who have intermediate poor risk disease include combinations of immunotherapies with targeted therapies like pembrolizumab with axitinib or avelumab with axitinib. Dr. Gilligan: So then just to be clear, these are drugs that are already being used, have already been shown to work, and we're trying to see if we combine them do we get a better result than using them by themselves. Dr. Zhang: That's right. And I think that's a main point. If two agents work on their own, can they be combined to work better? It is important to note that we must follow these patients for their side effects to make sure that the benefit of the triplet therapy would be worth the potential added toxicity of this combination. Dr. Gilligan: So as you mentioned, there's already a standard treatment that includes targeted therapies, immunotherapies, axitinib and pembrolizumab. What do you think is the interesting or different about the approach in this study? Dr. Zhang: The main difference of this triplet combination is the addition of ipilimumab which is a CTLA 4 inhibitor. This is even a bit of a stronger immunotherapy, which targets the dendritic cell interaction with cells to activate the immune cells even more. And so we know that ipilimumab in kidney cancer does drive increase the ability for us to achieve a complete response, meaning that this combination is a really active immunotherapy combination for metastatic kidney cancer. So if we can add the ipilimumab effect with a very strong targeted effect of the cabozantinib the thought is that this triplet might be even more effective than the current standard of care, pembrolizumab-axitinib or avelumab-axitinib combinations. Dr. Gilligan: Thank you for clarifying that. Just to make sure our listeners are clear on this. They're two doublets that are already approved—two kinds of immunotherapy or immunotherapy combined with targeted therapy. This will be the first triplet, if I understand correctly, that if this is shown to be more effective, it would be the first triplet therapy where we're using three different agents, our strongest immunotherapy combined with targeted therapy. Is that a fair summary? Dr. Zhang: Absolutely. I think that's a great summary. Dr. Gilligan: So how will success be evaluated? What are the endpoints for this? Dr. Zhang: Success for this particular study will be evaluated by improving time until tumor growth and the safety of the triplet combination so the primary outcome of this particular study is improving progression free survival. But one of the key secondary endpoints, of course, is to make sure that the benefit of this triplet is worth the potential combined side effects. And then also to follow patients and see if it also improves survival to make patients live longer. Dr. Gilligan: Do we have any sense of how long it'll be before we see outcomes from this? Or results? Dr. Zhang: This is an ongoing international trial enrolling in the US but also spanning Europe, Asia, South America, Australia, and New Zealand sites. It will enroll up to 676 patients, and it's open currently. And patients should discuss it with their oncologist and see if it's open in a site close to them. Dr. Gilligan: Dr. Grivas earlier told us about some of the side effects or risks with immunotherapy. This is combining immunotherapy with targeted therapy. Can you say a little bit about what we're gonna be watching for in terms of side effects or what we might expect? Dr. Zhang: Sure. I think all of the immunotherapy side effects that Dr. Grivas told us about pertain to this study as well. The rashes, the diarrhea, inflammation of the lungs or liver, and affected endocrine dysfunction. But the targeted therapies can also have high blood pressure, rashes on the hand and feet, so called hand foot syndrome, also diarrhea, and elevation of liver enzymes, as well as the loss of protein in the urine. I think the one overlapping toxicity of cabozantinib with a combination of ipilimumab and nivolumab, the immunotherapy combination, is the diarrhea. So patients who start on this trial should be careful to report any diarrhea early on so that their oncologist and their investigators on the study can get an early handle and manage their diarrhea well. Dr. Gilligan: Thank you. That's very helpful. One last question, I want to get back to that issue of eligibility. Sometimes when cancer patients want to go on a trial and they find that they are told they're not eligible to go on, this trial looking at intermediate risk patients specifically so a good risk patient might want to go on it and couldn't. Can you say a little bit about how those decisions are made and what the rationale for selecting groups of patients for trials is? Dr. Zhang: Sure. We know that the IMDC criteria were really made in the setting of targeted therapies, and they were a set of prognostic markers and markers of inflammation, for example, and of time from initial diagnosis to treatment. But now they've been used often as stratification markers in our treatment trials and as selection now for eligibility. In particular for this patient population, ipilimumab, nivolumab seem to have more benefit in this intermediate and poor risk population. And so that's why, for this particular study, they're selecting specifically those patients with intermediate poor-risk disease. Dr. Gilligan: So we want to focus on the patients who are most likely to benefit, it sounds like you're saying. Dr. Zhang: That's right. So the favorable risk patient population do have a better prognosis in general, but those patients may not have as much benefit from the immunotherapy doublet. Dr. Gilligan: All right. Thank you. Well, that brings us to the end of this podcast. Thanks for listening. There are many different clinical trials currently enrolling people with genitourinary cancers. If you're wondering whether participating in a clinical trial might be right for you, please talk to your health care team. This is Timothy Gilligan. Thank you very much. ASCO: Thank you, Drs. Gilligan, Pal, Grivas, and Zhang. Visit www.cancer.net/clinicaltrials to learn more about participating in clinical trials. All treatments have side effects—please talk to your health care team about possible side effects to watch out for. And if this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play. This Cancer.Net podcast is part of the ASCO Podcast Network. This collection of 9 programs offers insight into the world of cancer care, covering a range of educational, inspirational, and scientific content. You can find all 9 shows, including this one, at podcast.asco.org. Cancer.Net is supported by Conquer Cancer, the ASCO Foundation, which funds breakthrough research for every type of cancer, helping patients everywhere. To help fund Cancer.Net and programs like it, donate at conquer.org/donate.
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 world’s leading professional organization for doctors who care for people with cancer. 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. 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 clinical trials described here may no longer be enrolling patients, and final results are not yet available. Before any new cancer treatment can be approved for general use, it must be studied in a clinical trial in order to prove it is safe and effective. In today’s podcast, members of the Cancer.Net Editorial Board discuss 3 clinical trials that are exploring new treatment options across prostate, bladder, and kidney cancer. This podcast will be led by Dr. Brian Shuch, Dr. Neeraj Agarwal, Dr. Petros Grivas, and Dr. Sumanta (Monty) Pal. Dr. Shuch is the director of the Kidney Cancer Program at UCLA Health and the Alvin & Carrie Meinhardt Endowed Chair in Kidney Cancer Research at the institution. He has served in a consulting or advisory role for Bristol-Myers Squibb. Dr. Agarwal directs the Genitourinary Oncology Program at the Huntsman Cancer Institute at the University of Utah. He has served in a consulting or advisory role for AstraZeneca, Bristol-Myers Squibb, Exelixis, and Merck. 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. He has served in a consulting or advisory role for AstraZeneca, Bristol-Myers Squibb, Exelixis, and Merck. Dr. Pal is co-director of City of Hope's Kidney Cancer Program and is the head of the kidney and bladder cancer disease team at the institution. He has served in a consulting or advisory role for Bristol-Myers Squibb and Exelixis. View full disclosures for Dr. Shuch, Dr. Agarwal, Dr. Grivas, and Dr. Pal at Cancer.Net. Dr. Shuch: Hi, I'm Dr. Brian Shuch from UCLA's Institute of Urologic Oncology. And I'm really thrilled to moderate today's Cancer.Net podcast on GU clinical trials. I'm joined today by Dr. Neeraj Agarwal from Utah's Huntsman Cancer Center, Dr. Petros Grivas from the University of Washington's Fred Hutch Cancer Center, and Dr. Sumanta Pal from the City of Hope Cancer Center. Thanks for being here today, and we'll jump in to discuss 3 clinical trials in the urologic cancer space, one for prostate, one for bladder, and one for kidney cancer. Let's discuss some of the goals of clinical research first, okay? Neeraj, can you let us know what is the purpose of a clinical trial, and the ultimate goal? Dr. Agarwal: All these clinical trials aim to identify better treatments with the hope that the treatment will be safe and effective. An ultimate goal for all the clinical trials is to get approval [from the FDA for the routine use of the new treatments being tested.] I'd like to add, that the way I explain this to my patient, a clinical trial is the only way I can get cutting-edge therapy for my patients in my clinic without having to wait for many years for FDA approval of those drugs. Dr. Shuch: Petros, it seems that patient engagement is really essential to this type of clinical research. What is the patient's role here, and what can they expect by participation in a clinical study? Dr. Grivas: They can directly help [the research team] define better treatments and also improve existing therapies. And they can do that by either participating in clinical trials directly, and can also help us find the clinical questions. And the patient advocate groups are helping us do that by giving us input how to design clinical trials. And, of course, a number of trials that we're conducting are focusing on disease prevention or treatment of the cancer. And I think the patient's role overall is critical in every patient who's asked their provider about clinical trials. Dr. Shuch: So Monty, for your patients, how do you ensure patients are safe when they participate on these types of trials? Dr. Pal: Safety is our primary concern when conducting a research study. The patients are taking risks by participating, and these risks should be very clearly delineated in the context of a consent form. It's really critical that we, as investigators, perform very close monitoring in association with our patients. But we also have very intensive oversight of our clinical trials by independent monitoring committees, by the drug companies, and even the FDA. Now, trials can actually be closed early if there are safety concerns that emerge, or if drugs don't appear to be effective. Keep that in mind. Dr. Shuch: Got it. It's reassuring that for these types of trials, there's very close monitoring. So Petros, with the potential risk that we discussed, why would a patient participate? What are the benefits here? Dr. Grivas: Brian, this is a critical question. And I think the purpose of cancer research and clinical trials is to try to benefit the patient individually, but also to try to move the field forward, in terms of more knowledge about cancer research, also benefit the community and the society, in general. Dr. Shuch: How does a patient identify if a clinical trial's right for them? And how can they potentially participate? Dr. Agarwal: I think the most important role is of the physician who is seeing the patient. And the physician may alert you to a specific clinical trial that is focused on your current condition. So maybe 10 or 15 or 20 clinical trials you saw on the Huntsman Cancer Institute website, but maybe 1 or 2 are specifically needed for a patient's given situation. Also, not every center has a clinical trial for every condition. Dr. Shuch: We’ll jump in to discuss 3 clinical trials that were chosen by members of Cancer.Net editorial board for genitourinary cancers. And they were basically chosen from the Trials in Progress abstracts that were submitted and presented at the ASCO GU 2020 Symposium. So because these are ongoing clinical trials, we may not have final results for these trials at this time. But I'd like to note that none of the members of this discussion have any direct involvement for these trials. For reference, all relevant disclosures can be found on the notes for this episode of Cancer.Net. So let's jump in. Neeraj, let's discuss the KEYLYNK-010 study. [Study of Pembrolizumab (MK-3475) Plus Olaparib Versus Abiraterone Acetate or Enzalutamide in Metastatic Castration-resistant Prostate Cancer (mCRPC) (MK-7339-010/KEYLYNK-010) (KEYLYNK-010)] Can you briefly summarize this study for us? Dr. Agarwal: So this study is for patients who have progressive metastatic castrate-resistant prostate cancer, meaning the metastatic prostate cancer or advanced prostate cancer, which has already progressed on multiple previous lines of therapy, including chemotherapy and 1 of the novel hormonal therapies, which include enzalutamide and abiraterone. These are all standard therapies which are approved currently by FDA for treatment of our patients. Before I talk about this clinical trial, which includes multiple drugs, which is basically testing a combination of immunotherapy, pembrolizumab, with olaparib, which is a PARP inhibitor—and I'm going to explain those drugs in a moment—and comparing these drugs with other drugs, which are already approved by FDA and include enzalutamide and abiraterone. These drugs are manufactured by Merck, AstraZeneca, Pfizer, and Janssen. And I have consulted on a scientific advisory boards to all these companies and received honoraria for consulting to these companies. So with that in the backdrop, I'd like to go ahead and briefly summarize this study. The patients who are progressing on the standard treatment option for metastatic castrate-resistant prostate cancer, including prior chemotherapy, and 1 of these novel hormonal therapies, which include abiraterone or enzalutamide, but not both, these patients are randomized on a 1-on-1 fashion to the novel combination of pembrolizumab with olaparib versus other hormonal therapy, which the patient has not received in the past. The patient's disease has progressed on abiraterone or enzalutamide. Then they are randomized to the novel combination pembrolizumab with olaparib versus abiraterone or enzalutamide. Dr. Shuch: So Neeraj, what's the current standard of treatment for these patients at this time? Dr. Agarwal: The current options are very limited. I would say the only chemotherapy, which may be used again, is docetaxel. Sometimes, we re-treat patients with 1 of these drugs on which they have already progressed. Cabazitaxel is another drug which can be used. But please note that by the time patients have already had disease progression on these previous therapies, the expected benefit by trying these currently available options are very limited. Most of the time, patients experience disease progression within 3 to 4 months on these currently-approved medications. Dr. Shuch: So what is the exact problem that you're trying to solve or show with this study? Dr. Agarwal: So pembrolizumab is an immunotherapy, and it’s already approved for patients with multiple types of cancer. Olaparib is an oral pill which is already approved for patients with advanced breast cancer and ovarian cancer. Olaparib works by incapacitating the cancer cells from repairing their DNA, which in turns lead to cancer cell death. Taking a step back, if when we treat patients with olaparib, these cells also get unusually sensitive to action by concomitant treatment with immunotherapy. And this is based on the laboratory data, pretty strong laboratory data. And hence, there is a rationale for combining pembrolizumab with olaparib. And what olaparib is doing is, it is killing the cancer cells by incapacitating them from repairing their DNA, and simultaneously making them very sensitive to action by immunotherapy. And then we are using pembrolizumab at the same time, which is immunotherapy, and hence we expect these 2 drugs to synergize, and lead to an exponential increase in cancer cell death. Dr. Shuch: So Neeraj, so it sounds like there's pretty strong scientific rationale. But what question does this study aim to answer? Patients want to live longer? They want to be more stable on therapy? Dr. Agarwal: The study has 2 major primary endpoints, which basically means 2 major questions the study is asking. Number 1 is, are patients going to live longer when they receive this novel combination versus standard therapy? And secondly, are they going to respond for [a] longer time, meaning they will have a longer duration of disease control defined as the radiographic progression-free survival. That is another primary endpoint of the study. So the study is asking whether patients are living longer, with better control of their disease with this novel combination. Dr. Shuch: So Neeraj, with this new approach, are there any specific risks that patients would want to know about for this type of study? Dr. Agarwal: Pembrolizumab is already FDA-approved for more than 10 different kinds of cancers at least. This is an immunotherapy, which basically up-regulates our immune system in a rather non-specific way. Most of the patients, the vast majority of patients take pembrolizumab very well with minimal side effects. But then a small minority of patients, I would say somewhere around 4 to 5 percent, patients have hyper activation of the immune system, which can attack our own organs. So the most common side effects with any immune checkpoint inhibitor like pembrolizumab include diarrhea, liver toxicity, skin toxicity, and less frequently lung toxicity, or attack of immune system on the endocrine glands. These are only some of the toxicities which we usually see on our clinic, but it doesn't mean other rare toxicities may not happen. So these drugs require close monitoring. They're given every 3 weeks. So pembrolizumab, especially, is given every 3 weeks. And it is very important that patients are seen regularly by their oncology providers, so that if there are any of these toxicities are happening, they can be controlled at a much earlier stage, rather than becoming very severe and being picked up at a more severe stage. So I just want to add the toxicities of olaparib, which is already approved for patients with breast cancer and ovarian cancer. So we are not talking about any experimental drugs here for human beings. Both of these drugs are approved for various cancers already, with very well-defined toxicity profile. The combination is unique. Combination is being tested for the first time. So olaparib can cause bone marrow suppression, which basically means it can lead to anemia, low platelet counts, and low neutrophils, which are the defense cells fighting for us against infection. Most of these toxicities are easily manageable by modifying the dose of olaparib. Dr. Shuch: Neeraj, it sounds like this could be a really important study, and we'll keep an eye out for future updates. Please keep us posted. So let's move on to some of the exciting kind of work in bladder cancer. Petros, can you discuss this ongoing study that was presented at ASCO GU, the KEYNOTE-866 protocol? [Perioperative Pembrolizumab (MK-3475) Plus Neoadjuvant Chemotherapy Versus Perioperative Placebo Plus Neoadjuvant Chemotherapy for Cisplatin-eligible Muscle-invasive Bladder Cancer (MIBC) (MK-3475-866/KEYNOTE-866) (KEYNOTE-866)] Dr. Grivas: Sure. Before I start, I want to say that I have done consulting with this trial sponsor, which happens to be Merck, for unrelated reasons and not for this trial. And this trial is open in our institution, but I'm not involved directly into that study. This particular clinical trial is trying to evaluate the following question. Right now, the standard of care for patients who are aiming to go for removal of the bladder—we call this radical cystectomy—is to get chemotherapy with the regimen consisting of gemcitabine and cisplatin combination chemotherapy before cystectomy. We call this pre-operative, before the operation, or neoadjuvant cisplatin-based chemotherapy. And that's a standard of care in patients who are fit enough to tolerate this study, because this study can cause side effects. So the question is, can you now use immunotherapy, in particularly this drug called pembrolizumab, which is activating the immune system, in combination with chemotherapy. So chemotherapy plus, pembrolizumab, as compared to chemotherapy plus placebo before patients get cystectomy, removal of the bladder. Dr. Shuch: So these are patients who are going to go for surgery? Dr. Grivas: That is correct. This patient population are those patients who have made a decision to go for removal of the bladder, and we call this, as I mentioned, radical cystectomy. And I mention this because there are some other treatment approaches. Dr. Shuch: The current standard of care is chemotherapy and then surgery. So what is the problem that the researchers are trying to solve? Dr. Grivas: The main question is, does the addition of this immunotherapy to chemotherapy increases chance and [the likelihood of] not finding any residual cancer when the bladder is removed, and whether it actually increased the time of being cancer-free and alive down the road. So does the addition of immunotherapy to chemotherapy improves how these patients do over time, in terms of less of cancer recurrence, meaning cancer coming back, and longer life? Dr. Shuch: Okay. So you want to see the tumors disappear, and then you want to prevent patients from having recurrences with this study. Dr. Grivas: That is correct, and ideally, live longer, if possible. Dr. Shuch: And how was it specifically designed? What was the rationale with this type of approach? Dr. Grivas: Brian, this is an important question because we have to use previous information to inform the design of those trials. And I would mention that there are some observations about chemotherapy and immunotherapy combinations might work well in other cancer types. And particularly, in patients with bladder cancer, there were a few previews, smaller-sized clinical trials that showed promising results, meaning higher chance of making the cancer disappear when they take the bladder out. And because those trials were very promising and also showed that the combination of chemotherapy and immunotherapy was feasible, then the bigger trials now being launched to confirm the results and compare this combination with the standard of care right now. So strong previous data supports this larger trial to evaluate whether this addition makes sense. Dr. Shuch: So, Petros, patients generally are going to go to surgery. You're giving them a different medication, immune medication. What would be additional risk that patients would have with this approach? Dr. Grivas: So every time you add a new therapy, there is a chance of side effects as Dr. Agarwal mentioned before. And particularly, when you add immunotherapy, there is a small but real chance of having immunotherapy-related adverse events. And that's what we call side effects from a very activated active immune system. And I think it's important to have this discussion with the patient about benefits or risks before the trial starts. And before the patient makes a decision. Overall, these immunotherapy-related adverse events usually, as I mentioned, are not very common, especially when we compare the immunotherapy with the chemotherapy. However, we have to be very careful, especially with a combination. And these patients are monitored very closely for any side effect that might happen. And I think education is important for both the patient and the medical provider team, how to monitor and do a close observation for those side effects. The side effects of chemotherapy are standard. And that is something that's also a part of the discussion with the patient. Dr. Shuch: Got it. And is this still open? And when do you think we'll see results for this work? Dr. Grivas: Yes. The trial is still open. There is a way to go. It started accrual fairly recently, and I think their efforts for accruing patients in multiple cancer centers. So I would definitely consider this clinical trial for patients who are thinking about getting removal of the bladder and who [are well enough to] get chemotherapy, and they can discuss that option with a medical provider because the trial's going to be open at their cancer center or another cancer center. So definitely, it’s open and accruing patients. Dr. Shuch: I see. It seems very exciting that they're moving this type of therapy to a new space. Petros, keep us posted as this trial progresses. Dr. Grivas: Thank you. Will do. Dr. Shuch: So moving on to kidney cancer. Monty, let's discuss this PDIGREE trial. [Immunotherapy With Nivolumab and Ipilimumab Followed by Nivolumab or Nivolumab With Cabozantinib for Patients With Advanced Kidney Cancer, The PDIGREE Study] Besides obviously having a very interesting name, it seems like it's a pretty novel type of approach. Can you briefly summarize the study and design? Dr. Pal: Yeah. Thanks, Brian. So the intent of this study is to take patients with advanced kidney cancer—these are folks where the cancer has [spread] beyond the borders of the kidney to the lungs, to the liver etc. All patients receive standard immune-based treatment in the upfront setting. And then a couple of months in, they actually look at the response that they've achieved, and based on that, decide on different lines of treatment beyond that. Dr. Shuch: So who is the ideal patient for this study? Who is it intended for? Dr. Pal: Yes. So this particular study, as I've mentioned, is really for those patients with advanced disease. And beyond that, we in the clinic are using different criteria [to assess] how functional a patient is. It's based on their labs, etc., to define whether or not they have what's termed good risk, intermediate risk, or poor risk. And I think as you're looking at treatment options, as a patient with kidney cancer, it's important to figure out which one of those risk criteria you fit into. This particular trial is intended for patients with intermediate and poor risk. Dr. Shuch: Got it. So these are patients that are newly diagnosed. Correct? Dr. Pal: Exactly. Exactly. Dr. Shuch: So what is the current standard of care for these patients? What would you give them outside of this trial? Dr. Pal: There's a number of options for kidney cancer. When I started in this business, we only had about 2 to 3 treatments for the disease. And now, it's expanded to more than 12 FDA-approved therapies, which is just mind-boggling. Typically, if you're just diagnosed with advanced or metastatic kidney cancer, you'll start with a combination of immune treatments, 2 immune therapies. And that's really the basis of this particular trial. Or you might get a mix of targeted treatment and immune treatment up front. Dr. Shuch: So Monty, if we have so many exciting therapies, what is the problem that the clinical trial team is trying to solve here? Dr. Pal: Great question. I think the big issue is that we know that patients who aren't doing well in therapy need to be switched. We know that patients who are doing exceptionally well on therapy can be continued on their current treatment. For the in-betweens, for patients who might have some stability in their tumors, but maybe not the type of shrinkage that we want to see, we really don't know what the best option is. And that's really where the PDIGREE trial comes into play. Dr. Shuch: So with that in mind, how is it designed to kind of answer that question? Dr. Pal: So again, we're taking patients who are receiving immune therapy in the upfront setting. We're taking a look at their response at around the 3-month mark. And typically, if you're a patient with kidney cancer, that's how often I would image you with scans. So at the 3-month mark, we look and see. If you've got a complete response—I think it's pretty intuitive—you're just going to continue on immune treatment. If you're actually having a very poor response, meaning the cancer is continuing to grow, it's migrating to new sites, you'll go on to targeted therapy. On the other hand, if you're in-between, if tumors are maybe shrinking more modestly, or just staying the same size for the most part, that's when you would be randomized to either continue on immune therapy alone, or go on a mix of targeted therapy with immune therapy. Dr. Shuch: So what is the overall question that the study is hoping to answer? The patients who are getting that additional targeted therapy, what is the hope for them? Dr. Pal: I think really what we're hoping to see is that those patients actually have delays in their cancer progression. There will be a longer time until they see their cancer grow. Furthermore, we're hoping, actually, that we might improve the survival of these patients. Dr. Shuch: Got it. So the patients who are starting this therapy, and they have an additional medication, that targeted drug, what would their specific risk be by participating in this study with that drugs? Dr. Pal: So we've had some great conversations with Dr. Agarwal around the targeted therapy in prostate cancer. He was talking about PARP inhibitors. In kidney cancer, the general principle of targeted therapies are they tend to cut off the blood supply to tumors. But they don't just do it there. They can do it in other organ systems, as well. By virtue of that, you can have a handful of different side effects, including hand-foot syndrome, which is peeling of the skin on the hands and soles of the feet. You can potentially have high blood pressure as a consequence of that mechanism. You can also have diarrhea. These tend to impact the gut. Those tend to be some of the principal side effects. But, of course, I always refer patients to the consent form for these studies for a more exhaustive review. Dr. Shuch: Got it. But some patients may not have any of these side effects. True? Dr. Pal: You're absolutely right. It's just amazing to me that I have more than a handful of patients in my practice who experience little or none of these toxicities. Having said that, it's still so important to disclose the possibilities when you're discussing these trials. Dr. Shuch: Got it. Is this trial still open to patients? And when do you think the results would be available? Dr. Pal: So at this particular trial is planning to accrue several hundred patients. And we're really in the trial's infancy. We've just had over about 150 patients accrued to date. So there's still ample opportunity to get the study for your patients in practice. And to the patients who are listening to this, it's certainly a trial that I would like you to inquire about at your respective cancer centers. It's open all over the country. Dr. Shuch: Well, Monty, that seems really fascinating. The idea that it's an adaptable trial, that patients start on therapy, and you see how they do. We'll definitely keep an eye out for that trial in the next few years. Dr. Pal: Thanks a lot, Brian. Dr. Shuch: Great. So thanks to our guests. Thank you for tuning into this podcast. I'd like to thank my guests Dr. Neeraj Agarwal, Dr. Petros Grivas, and Dr. Sumanta Pal. There are many types of clinical trials for urologic cancers that are ongoing, all with the shared goal of improving the way we treat these diseases. If you're wondering about participating in a clinical trial that might be right for you, definitely, talk to your healthcare provider. Please tune in next time for further discussions on additional advances in our urologic cancer field. Thank you so much. ASCO: Thank you, Drs. Shuch, Agarwal, Grivas, and Pal. Visit www.cancer.net/clinicaltrials to learn more about participating in clinical trials. All treatments have side effects—please talk to your health care team about possible side effects to watch out for. And if this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play.
Dr. Jack West, medical oncologist at City of Hope Cancer Center, considers how the risks & new medical landscape borne of COVID-19 is streamlining cancer care in some constructive ways and bringing overdue advances to how we run clinics & meetings.
Dr. Stacy Gray from City of Hope Cancer Center speaks to host Jack West about the evolution of her career focus on adoption of and attitudes about molecular testing, including an early interest in direct-to-consumer (DTC) genetic testing.
Dr. Yuman Fong, surgical oncologist at City of Hope Cancer Center, recounts how he defined career goals, the experience of raising 3 daughters in NYC with a wife who is a successful lawyer, & his efforts to balance his work with personal commitments.
Dr. Rahul Jandial, MD, Ph.D. is a dual-trained brain surgeon and neuroscientist at City of Hope Cancer Center in Los Angeles. Rahul sits down in the attic to discuss intermittent fasting, emigrating from India as an eight-year-old and how he redirected some of his negative qualities into positive ones. Dax wonders if it takes a certain level of arrogance to choose brain surgeon and Rahul gives a breakdown of the human body as it relates to mechanics. The two talk about modern approaches to fighting cancer and the importance of keeping the brain stimulated.
Dr. Rahul Jandial, MD, Ph.D. is a dual-trained brain surgeon and neuroscientist at City of Hope Cancer Center in Los Angeles. Rahul sits down in the attic to discuss intermittent fasting, emigrating from India as an eight-year-old and how he redirected some of his negative qualities into positive ones. Dax wonders if it takes a certain level of arrogance to choose brain surgeon and Rahul gives a breakdown of the human body as it relates to mechanics. The two talk about modern approaches to fighting cancer and the importance of keeping the brain stimulated.
TRANSCRIPT 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. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Hello, and welcome to the ASCO Guidelines Podcast series. My name is Shannon McKernin, and I'm interviewing Dr. Joe Mikhael from the City of Hope Cancer Center and International Myeloma Foundation, lead author on "Treatment of Multiple Myeloma: ASCO and CCO Joint Clinical Practice Guideline." Thank you for being here today, Dr. Mikhael. It's a pleasure to be with you. So first, can you give us some context as to why this guideline was developed? Well, we had a lot of ideas when we put together this guideline, but most importantly, multiple myeloma continues to be a rare disease in the cancer world. It really only accounts for about 1% to 2% of cancers. So for the practicing oncologist, they spend perhaps 3-ish percent of their time doing multiple myeloma. And when you add to that there has been really a revolution in myeloma with new drugs approved, new treatments, new approaches, it really leaves the general oncologist with a complexity of how to treat this disease. And so we wanted to create a very practical guideline that would give very precise advice to walk through how one would care for a multiple myeloma patient, right from their diagnosis to indeed relapse disease. We felt this approach was so important now, more than ever, because of the fact that myeloma has really changed so much, and now, thankfully, we're seeing our patients live so much longer that the treatment options can become a little bit more complicated over time. Furthermore, we partnered with Cancer Care Ontario, because this was really felt to be not just an American phenomenon, but really a full North American phenomenon of how we could work together to really give practical advice as to how to treat this disease. So what are the key recommendations of this guideline? In this guideline, we focused really on the treatment of the disease itself. There have been other guidelines that have focused on supportive care and bone disease and multiple myeloma, but we really focused on the treatment of patients really from induction therapy through to relapse. So we spend time helping guide the decision around whether or not a patient is transplant eligible or ineligible, because that's really the first dividing marker in myeloma, because we know that transplant still has a role in myeloma, and eligible patients should have a transplant, or at least have access to a transplant. And historically, this was really done on the basis of age. But the guidelines helps the clinician see that it's really not just an age phenomena. It's really a decision based on comorbidities and really what's best for the patient. So we spend time helping making that decision, and then provide very practical advice as to how to treat a patient who's going to transplant versus a patient who's not going to transplant. We also, then, after the transplant, or in lieu of a transplant, we discuss the importance of continuous therapy, or sometimes called, maintenance therapy in myeloma. Again, we've seen maintenance therapy, now, have an impact on both progression free and overall survival. And so we felt it was really important to be very practical in giving advice as to what maintenance therapy agents to use and how to use them. And then lastly, the guideline provides a lot of practical advice as to a patient who has relapsed with multiple myeloma. We have so many choices now with three major classes of drugs of proteasome inhibitors, immuno-modulatory drugs, and now newer monoclonal antibodies, it can be difficult sometimes to know which combination to use. We know that triplet combinations tend to be preferred. So we walk through a number of those triplets and provide advice as how to explicitly use them. We do emphasize the importance of supportive care and of risk factor analysis throughout the guideline, so that we can understand the difference between high risk and low risk myeloma, so that we can understand how important a patient's comorbidities, especially in a disease that primarily affects older patients, can be managed. And so we try to do so in a comprehensive way, but one that really distills down to the critical pieces to allow the practicing clinician some real advice. So why is this guideline so important, and how will it change practice? There are several kinds of guidelines for multiple myeloma, but I really think this is a critical guideline because it is so clinical and practical in its essence. It's really designed to not just give the utopian view or the clinical trial view of a disease, but practically in the trenches, how do we use the drugs that we know are going to benefit our patients. Myeloma is one of the few cancers where we have seen a doubling, if not a tripling of survival in the last decade, because of so many of these new agents. And so making sure that our patients are treated optimally really is important. And we want to be able to ensure that they receive the best therapy possible, so they can live a longer life, but also live it with a greater quality of life. And so finally, how will these guideline recommendations affect patients? Well, we really hope that this is going to help patients all across North America and the whole world, because it will give very concrete advice to the practicing clinician in how to approach the disease. And one of the things I think will directly impact patients, if you will, right away is one of the themes of these guidelines, which is that you don't treat a patient simply based on the biopsy or simply based on their age, but that it is really a complex network of comorbidities, risk factors from the disease itself, the potential side effects of certain drugs, and a patient's own very personal history. It really fits in with the ASCO modality that we have of ensuring that we bring personalized medicine to our patients. And so this will allow the person who's reading it and who's applying it to their patient to recognize the importance of general guidelines, but also of applying it to the specific patient they care for. Because as I like to say, we don't treat multiple myeloma, we treat people. And so hopefully, this will allow the clinician to have that precision to care for their patient in the best way possible. Great. Thank you for that overview of this guideline, and thank you for your time today Dr. Mikhael. It's been a real pleasure. Thank you very much. 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/hematologic-malignancies-guidelines. And if you've enjoyed what you've heard today, please rate and review the podcast, and refer the show to a colleague.
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. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Hello, and welcome to the ASCO Guidelines Podcast series. My name is Shannon McKernin, and I'm interviewing Dr. Joe Mikhael from the City of Hope Cancer Center and International Myeloma Foundation, lead author on "Treatment of Multiple Myeloma: ASCO and CCO Joint Clinical Practice Guideline." Thank you for being here today, Dr. Mikhael. It's a pleasure to be with you. So first, can you give us some context as to why this guideline was developed? Well, we had a lot of ideas when we put together this guideline, but most importantly, multiple myeloma continues to be a rare disease in the cancer world. It really only accounts for about 1% to 2% of cancers. So for the practicing oncologist, they spend perhaps 3-ish percent of their time doing multiple myeloma. And when you add to that there has been really a revolution in myeloma with new drugs approved, new treatments, new approaches, it really leaves the general oncologist with a complexity of how to treat this disease. And so we wanted to create a very practical guideline that would give very precise advice to walk through how one would care for a multiple myeloma patient, right from their diagnosis to indeed relapse disease. We felt this approach was so important now, more than ever, because of the fact that myeloma has really changed so much, and now, thankfully, we're seeing our patients live so much longer that the treatment options can become a little bit more complicated over time. Furthermore, we partnered with Cancer Care Ontario, because this was really felt to be not just an American phenomenon, but really a full North American phenomenon of how we could work together to really give practical advice as to how to treat this disease. So what are the key recommendations of this guideline? In this guideline, we focused really on the treatment of the disease itself. There have been other guidelines that have focused on supportive care and bone disease and multiple myeloma, but we really focused on the treatment of patients really from induction therapy through to relapse. So we spend time helping guide the decision around whether or not a patient is transplant eligible or ineligible, because that's really the first dividing marker in myeloma, because we know that transplant still has a role in myeloma, and eligible patients should have a transplant, or at least have access to a transplant. And historically, this was really done on the basis of age. But the guidelines helps the clinician see that it's really not just an age phenomena. It's really a decision based on comorbidities and really what's best for the patient. So we spend time helping making that decision, and then provide very practical advice as to how to treat a patient who's going to transplant versus a patient who's not going to transplant. We also, then, after the transplant, or in lieu of a transplant, we discuss the importance of continuous therapy, or sometimes called, maintenance therapy in myeloma. Again, we've seen maintenance therapy, now, have an impact on both progression free and overall survival. And so we felt it was really important to be very practical in giving advice as to what maintenance therapy agents to use and how to use them. And then lastly, the guideline provides a lot of practical advice as to a patient who has relapsed with multiple myeloma. We have so many choices now with three major classes of drugs of proteasome inhibitors, immuno-modulatory drugs, and now newer monoclonal antibodies, it can be difficult sometimes to know which combination to use. We know that triplet combinations tend to be preferred. So we walk through a number of those triplets and provide advice as how to explicitly use them. We do emphasize the importance of supportive care and of risk factor analysis throughout the guideline, so that we can understand the difference between high risk and low risk myeloma, so that we can understand how important a patient's comorbidities, especially in a disease that primarily affects older patients, can be managed. And so we try to do so in a comprehensive way, but one that really distills down to the critical pieces to allow the practicing clinician some real advice. So why is this guideline so important, and how will it change practice? There are several kinds of guidelines for multiple myeloma, but I really think this is a critical guideline because it is so clinical and practical in its essence. It's really designed to not just give the utopian view or the clinical trial view of a disease, but practically in the trenches, how do we use the drugs that we know are going to benefit our patients. Myeloma is one of the few cancers where we have seen a doubling, if not a tripling of survival in the last decade, because of so many of these new agents. And so making sure that our patients are treated optimally really is important. And we want to be able to ensure that they receive the best therapy possible, so they can live a longer life, but also live it with a greater quality of life. And so finally, how will these guideline recommendations affect patients? Well, we really hope that this is going to help patients all across North America and the whole world, because it will give very concrete advice to the practicing clinician in how to approach the disease. And one of the things I think will directly impact patients, if you will, right away is one of the themes of these guidelines, which is that you don't treat a patient simply based on the biopsy or simply based on their age, but that it is really a complex network of comorbidities, risk factors from the disease itself, the potential side effects of certain drugs, and a patient's own very personal history. It really fits in with the ASCO modality that we have of ensuring that we bring personalized medicine to our patients. And so this will allow the person who's reading it and who's applying it to their patient to recognize the importance of general guidelines, but also of applying it to the specific patient they care for. Because as I like to say, we don't treat multiple myeloma, we treat people. And so hopefully, this will allow the clinician to have that precision to care for their patient in the best way possible. Great. Thank you for that overview of this guideline, and thank you for your time today Dr. Mikhael. It's been a real pleasure. Thank you very much. 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/hematologic-malignancies-guidelines. And if you've enjoyed what you've heard today, please rate and review the podcast, and refer the show to a colleague.
Researcher Linda Malkas, Ph.D., dean of translational science and the M.T. & B.A. Ahmadinia Professor in Molecular Oncology and associate chair in the Department of Molecular and Cellular Biology at City of Hope discusses cancer research, her story, and the background of City of Hope Cancer Center.
Today we will be discussing the modern management of colorectal liver metastases. For today's episode, we are excited to be welcoming on Dr. Yuman Fong, Sangiacomo Family Chair in Surgical Oncology and Surgical chair at City of Hope Cancer Center in California. Dr. Fong previously held the Murray F. Brennan Chair of Surgery at Memorial Sloan Kettering Cancer center, and is an international expert in both liver and pancreatic surgery.
Dr. Karen Reckamp of City of Hope Cancer Center reviews the concept of acquired resistance to targeted therapies in patients with a driver mutation and why it occurs.
Dr. Karen Reckamp of City of Hope Cancer Center reviews the concept of acquired resistance to targeted therapies in patients with a driver mutation and why it occurs.
Dr. Karen Reckamp of City of Hope Cancer Center reviews the concept of acquired resistance to targeted therapies in patients with a driver mutation and why it occurs.
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, describes the main types of kidney cancer and discusses the differences in their management
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, describes the main types of kidney cancer and discusses the differences in their management
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, describes the main types of kidney cancer and discusses the differences in their management
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, explains the range of options and his approach to second line treatment of kidney cancer.
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, explains the range of options and his approach to second line treatment of kidney cancer.
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, describes the role of surgery in the treatment of metastatic kidney cancer.
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, describes the role of surgery in the treatment of metastatic kidney cancer.
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, describes the role of surgery in the treatment of metastatic kidney cancer.
Dr. Karen Reckamp from City of Hope Cancer Center in Duarte, CA describes which patients with advanced NSCLC she seeks molecular marker testing on, and the particular markers she prioritizes.
Dr. Karen Reckamp from City of Hope Cancer Center in Duarte, CA describes which patients with advanced NSCLC she seeks molecular marker testing on, and the particular markers she prioritizes.
Dr. Karen Reckamp from City of Hope Cancer Center in Duarte, CA describes which patients with advanced NSCLC she seeks molecular marker testing on, and the particular markers she prioritizes.
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, explains the range of options and his approach to first line treatment of metastatic kidney cancer.
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, explains the range of options and his approach to first line treatment of metastatic kidney cancer.
Dr. Sumanta (Monty) Pal, medical oncologist at City of Hope Cancer Center in Duarte, CA, explains the range of options and his approach to first line treatment of metastatic kidney cancer.
Dr. Karen Reckamp, City of Hope Cancer Center, provides her perspective on the likelihood that molecular oncology principles and targeted therapies will become more broadly applicable for patients with squamous and other lung cancer subtypes.
Dr. Karen Reckamp, City of Hope Cancer Center, provides her perspective on the likelihood that molecular oncology principles and targeted therapies will become more broadly applicable for patients with squamous and other lung cancer subtypes.
Dr. Karen Reckamp, City of Hope Cancer Center, provides her perspective on the likelihood that molecular oncology principles and targeted therapies will become more broadly applicable for patients with squamous and other lung cancer subtypes.
Dr. Sumanta (Monty) Pal of City of Hope Cancer Center discusses the current role of interleukin-2 (IL-2) in the context of many other treatment alternatives for metastatic renal cell carcinoma.
Dr. Sumanta (Monty) Pal of City of Hope Cancer Center discusses the current role of interleukin-2 (IL-2) in the context of many other treatment alternatives for metastatic renal cell carcinoma.
Dr. Sumanta (Monty) Pal of City of Hope Cancer Center discusses the current role of interleukin-2 (IL-2) in the context of many other treatment alternatives for metastatic renal cell carcinoma.
Dr. Sumanta (Monty) Pal, City of Hope Cancer Center, summarizes basic stages of bladder cancer, value of surgery, and survival benefit of neoadjuvant (pre-operative) chemotherapy for higher risk muscle-invasive bladder cancer.
Dr. Sumanta (Monty) Pal, City of Hope Cancer Center, summarizes basic stages of bladder cancer, value of surgery, and survival benefit of neoadjuvant (pre-operative) chemotherapy for higher risk muscle-invasive bladder cancer.
Dr. Sumanta (Monty) Pal, City of Hope Cancer Center, summarizes basic stages of bladder cancer, value of surgery, and survival benefit of neoadjuvant (pre-operative) chemotherapy for higher risk muscle-invasive bladder cancer.
Dr. Sumanta (Monty) Pal of City of Hope Cancer Center in Duarte, CA describes optimal management of kidney cancer that is confined to the kidney, including surgery and the role of any additional post-surgical treatment.
Dr. Sumanta (Monty) Pal of City of Hope Cancer Center in Duarte, CA describes optimal management of kidney cancer that is confined to the kidney, including surgery and the role of any additional post-surgical treatment.
Dr. Sumanta (Monty) Pal of City of Hope Cancer Center in Duarte, CA describes optimal management of kidney cancer that is confined to the kidney, including surgery and the role of any additional post-surgical treatment.
Dr. Karen Reckamp, City of Hope Cancer Center, reviews her thought process in recommending a repeat biopsy at initial diagnosis or after progression for patients with advanced lung cancer.
Dr. Karen Reckamp, City of Hope Cancer Center, reviews her thought process in recommending a repeat biopsy at initial diagnosis or after progression for patients with advanced lung cancer.
Dr. Karen Reckamp, City of Hope Cancer Center, reviews her thought process in recommending a repeat biopsy at initial diagnosis or after progression for patients with advanced lung cancer.
Dr. Sumanta (Monty) Pal of City of Hope Cancer Center in Duarte, CA reviews a recommended approach to the workup of a kidney mass suspected to be a cancer.
Dr. Sumanta (Monty) Pal of City of Hope Cancer Center in Duarte, CA reviews a recommended approach to the workup of a kidney mass suspected to be a cancer.
Dr. Sumanta (Monty) Pal of City of Hope Cancer Center in Duarte, CA reviews a recommended approach to the workup of a kidney mass suspected to be a cancer.
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