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Vasari Singers, one of the UK's pre-eminent choirs, have titled their new album The Music Never Ends, referencing Michel Legrand and his celebrated song How do you Keep the Music Playing? And by the end of the album's twenty-one tracks, you'll wish it could be so. Raymond Bisha dips into the programme's multi-faceted offerings, while didgeridoo players should be on immediate standby to make a contribution. Listen up, and listen on.
Recorded: June 18th 2025 | Welcome back to the Back Of The Bus pod, this week we have our first ever guest and one of the boys, Thomas Edwards. Thomas is friends with Jack and Garrett and played football for the University of Tennessee and is now an emerging country music singer. He tells some stories of his playing days including a hilarious story of him playing hungover against Kentucky. We then dive into his music career so far and the journey he has been on since starting. He gets into his love of making music and how he loves just making people feel good in anyway that he can. Thomas drops some absolute bars throughout this episode that hit deep and is one of the most charismatic people you will meet. Enjoy fellas.See omnystudio.com/listener for privacy information.
After a long (and much-needed?) hiatus since 2022, Craig and Kevin are officially back with V2 of the Schizophrenic Music Podcast — and they're picking up right where they left off: unscripted, unpredictable, and unapologetically obsessed with all things music.In this episode, the guys catch you up on what's been going on during the break — creatively, personally, and musically. From late-night jam sessions to the challenges of recording, they dig into the differences between playing live vs. recording in the studio, and what makes each one its own kind of high.They also unpack the weird world of cover bands vs. tribute bands — is one more legit than the other? Is there artistry in imitation? Where do we draw the line?Finally, they muse about the future of music festivals — post-pandemic evolution, indie takeovers, AI-generated acts(?), and what's missing from the current scene.Expect real talk, deep dives, a little bit of chaos, and a lot of passion for music in all its forms.
The father/son duo recently released the 12-track record, Father and Son , featuring some of their favorite songs from The Beatles to Simon & Garfunkel
The father/son duo recently released the 12-track record, Father and Son , featuring some of their favorite songs from The Beatles to Simon & Garfunkel
Thank you for all of your support. Please let us know what you think about our podcast and what topic you may want to hear from us. Leaders, Lead Well!In music, some of the most memorable performances aren't about the notes musicians play—they're about the ones they leave out. The spaces between the sounds create rhythm, swing, and connection. What if leadership worked the same way? Take Count Basie's band, for example. Basie was famous for his minimalist piano style—he played fewer notes, giving the rhythm section room to groove and the soloists space to shine. The result? Music that felt effortless and alive. Leaders, like musicians, often feel the pressure to “play every note”—to solve every problem, attend every meeting, or micromanage every decision. But just as music depends on collaboration, so does effective leadership. Leaving space allows team members to take ownership, contribute creatively, and create synergy.Rich and Maikel jam to the beat of less is more on this episode of Mainline Executive Coaching ACT. Leaders, Lead Well!Thank you to all of our listeners in over 70 countries and 750 cities worldwide, we greatly appreciate your support! We truly hope that what we bring to our listeners will improve your ability as leaders.Mainline Executive Coaching ACT has been recognized by FeedSpot as one of the top Executive Coaching Podcast in the world based on thousands of podcasts on the web and ranked by traffic, social media, followers & freshness.https://blog.feedspot.com/executive_coaching_podcasts/Sign up for our newsletter:https://www.richbaronexecutivecoaching.com/contactDownload our document on the Hottest Item in Business Today.https://www.richbaronexecutivecoaching.com/resources2fbc974dRich Baron:rbaron@richbaronexecutivecoaching.comhttps://www.linkedin.com/in/rich-baron/https://www.richbaronexecutivecoaching.com/Maikel Bailey:mbailey@intelligentleadershipec.comhttps://www.linkedin.com/in/maikelbailey/https://maikelbailey.com/
Send us a textLee and Simon discuss what it is they are most proud of and the capacity to feel as if terrible events are gifts. Things covered: Not having a kitchen, Wolf ovens, removing fitted carpets from a place, Simon being met by a friend at St Pancras, Lee being proud of still being married to Bob, the challenges of a life, having had a difficult week (tummy anxiety), the feeling of underperforming at work, men being less able to communicate feelings (or not), texting a Jungian analysis, the feeling of a big week when it isn't really that big, how small things accumulate over time, Lee watching and seeing the photographs that Bob is taking while she is away, a period of difficulty as a gift, revisiting (briefly) that moment when Simon and Lee covered Simon's reaction to their first miscarriage (see episode whatever way back when), the capacity to view a difficult thing as a gift, the rhythm of loss, adapting to change in time, coming back to worm carnage, closed captions: unsettling music playing, discordant noise, John Williams and Jaws, being full sensory beasts.Get in touch with Lee and Simon at info@midlifing.net. ---The Midlifing logo is adapted from an original image by H.L.I.T: https://www.flickr.com/photos/29311691@N05/8571921679 (CC BY 2.0)
In this new episode, I have the pleasure of talking to Toku, vocalist and flugelhorn player from Japan. With his deep distinctive voice Toku takes us on a journey beyond musical genres, where artistry and improvisation only matter.The informations about Toku are on his website. You can also follow his Instagram page.Credits :- 10:37 - Toku – Love Is Calling You- 22:18 - Toku – I Think I Love You- 31:32 - Toku Ft. Aisha - Moonshine- 40:15 - Toku, Sarah Lancman, Noé Zagroun – How Do You Keep the Music Playing?- 50:33 - Toku – Be CarefulHébergé par Ausha. Visitez ausha.co/politique-de-confidentialite pour plus d'informations.
It's going to be a special Passover seder this year in Victoria, B.C. for The Klezbians, an all-woman musical group that performs Klezmer music. They're marking 10 years since the band formed to play professionally in 2014. And even before that, the band and their wider group of Jewish lesbian friends have been holding annual inclusive seders, by invitation only, at a private home. These seders started as an alternative to the women's unpleasant memories of their experiences as lesbians at their own traditional family seders, which were usually not welcoming spaces for them or their partners. Over the years, guests have created their own seder rituals, including making their own haggadah. The seder is usually accompanied by live klezmer performances of their favourite Passover songs. For a special Erev Passover edition of The CJN Daily, we're joined by two of The Klezbians to hear their heartwarming story: Debby Yaffe is a retired women's studies professor from the University of Victoria who plays guitar, and Susan Dempsey is a psychotherapist and counsellor who plays the accordion. What we talked about: Read more about the Klezbians on their official Facebook page Check out their music on YouTube Check out Bonjour Chai's “Third Annual Great Canadian Seder” Credits: The CJN Daily is written and hosted by Ellin Bessner (@ebessner on Twitter). Zachary Kauffman is the producer. Michael Fraiman is the executive producer. Our theme music is by Dov Beck-Levine. Our title sponsor is Metropia. We're a member of The CJN Podcast Network. To subscribe to this podcast, please watch this video. Donate to The CJN and receive a charitable tax receipt by clicking here. Hear why The CJN is important to me.
Morning Mixers shared their unique middle names. One Mixer stopped a long family tradition. Nikki's surgeon played "A Space Between" by the Dave Matthews Band during her colonoscopy, so Mixers called in with the music that was playing during their visits. Learn more about your ad choices. Visit podcastchoices.com/adchoicesSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.
Morning Mixers shared their unique middle names. One Mixer stopped a long family tradition. Nikki's surgeon played "A Space Between" by the Dave Matthews Band during her colonoscopy, so Mixers called in with the music that was playing during their visits. Learn more about your ad choices. Visit megaphone.fm/adchoices
To be fari sometimes I don't know what's going on in my house either
Hilario Durán, the Juno-winning and National Jazz Award-winning pianist and bandleader, is back with his first big band record in 17 years. Hilario joins Tom in the Q studio to talk about the new album, titled “Cry Me a River”. He also tells Tom about his musical journey from growing up in Havana to playing with some of the most influential figures in Cuban music, and what brought him to Canada in the late 1990s.
Episode 2364: Our random article of the day is How Do You Keep the Music Playing? (Johnny Mathis album).
https://www.andrewfreemanmusic.com/home --- Support this podcast: https://podcasters.spotify.com/pod/show/shawn-ratches/support
Introducing Deep Sleep Sounds - the ultimate solution for enhancing your relaxing moments. Immerse yourself in a world of tranquility with our carefully curated collection of soothing sounds. Whether you're studying, working, or simply seeking to unwind, Deep Sleep Sounds is your gateway to a heightened state of calm and serenity.For a better relaxation Deep Sleep Sounds Podcast offers a no ads program that helps you sleep during a full night without the ads: https://www.patreon.com/FullSoundsPodcastSubscribe to our email list for to get notifications every time a new episode comes out: https://full-sounds-podcast.ck.page/99b061d339 Subscribe to our Youtube Channel where we offer black screen sounds the perfect way to listen to our sounds without any distractions: https://www.youtube.com/@FullSoundsPodcastWant to listen to specific sounds please click here and select the sounds you want to listen to. We have a big variety of sounds: https://linktr.ee/fullsoundspodcastAmazon AffiliateThe perfect way to start your day is by exercising and meditating for that we research the best products that will help you archive exercising, meditation and start your day on a positive note:Links:Sleep Headphones Wirelesshttps://amzn.to/439rjvwAir Purifier for Homehttps://amzn.to/3D0pkicDiffuser & Essential Oil Sethttps://amzn.to/3rcHISrCopyright & FAQAll sounds from Deep Sleep Sounds Podcast are copyrighted and not permitted to be reused for commercial purposes.Study, Study Sounds, study time, study nature sounds, study meditation, fall, fall sleep, fall Deep Sleep Sounds, fall relaxing music, fall asleep fast, focus, focus sounds, focus meditation, focus relax, focus music for work, focus time, focus study, anxiety, anxiety relief, anxiety sounds, anxiety meditation, anxiety Deep Sleep Sounds, mental, mental sounds, mental meditation, mental health, mental Deep Sleep Sounds, sleep, Deep Sleep Sounds, sleep time, sleep massage, sleep rain, deep, Deep Sleep Sounds, deep sounds, deep meditation, deep relax, rest, rest time, rest sleep, rest sounds, rest music, stress, stress sounds, stress relax, stress meditation, stress peace, piano, piano sounds, piano relaxing music, piano to relax, piano songs, piano meditationAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy
On today's 1-18-22 Wednesday show: Move over "quiet quitting" there is a new job trend taking over, there's a new website that will tell you if you are getting in to Heaven, Selena is having second thoughts about her bachelorette party destination after her man decides where he is going for his bachelor party, a Lyft driver stabbed an annoying rider in Daly City, Netflix is looking for a flight attendant for their private jet, ticket prices are skyrocketing for the Niner game this Sunday, and a bunch of luxury cars were ruined in San Francisco flooding. Plus tons more!
In this episode I have fun conversation with singer, song writer and writer of young adult books. We has such a fun conversation in which she shares about her music career and her new album "Dear Dairy." She shares some very emotional feelings in this album. I highly recommend checking it out. Also in this podcast episode we have music by --- Send in a voice message: https://anchor.fm/jody-shuffield/message
As a marriage and family therapist in private practice for more than 4 decades, Sally Strosahl (LCPC) has heard countless stories from couples about distresses in their relationship as they move into retirement and get older. She felt called to write Loving Your Marriage in Retirement: Keep the Music Playing (2018). Sally offers an authentic and reassuring voice for couples who face a myriad of changes during this critical phase in their long-term relationship. Connect with Sallysally@sallystrosahl.comStrosahl, S. (2018). Loving Your Marriage in Retirement: Keep the Music Playing. In the Round Publishing.
"Teenage Mutant Ninja Turtles, Teenage Mutant Nija Turtles, Teenage Mutant Ninja Turtles, Heroes in a half-shell turtle power". Yep, that's about it. You watched the show, read the comics, saw the movies, and bought the merch. Now it's time to re-live that and play this new beat 'em up game by Tribute Games. Play single player or up to 6 friends. Play as your favorite turtle or play as Splinter or April.Get ready to kick some butt!!Support the show
Welcome to Secrets of Organ Playing Podcast #693! Today's guest is harpsichordist Alina Rotaru. Alina studied piano and choral conducting at the music academy in her hometown of Bucharest. After moving to Germany, she studied harpsichord with Siegbert Rampe and Wolfgang Kostujak at the Folkwang University of the Arts Essen, with Bob van Asperen at the Conservatorium van Amsterdam, and with Carsten Lohff and Detlef Bratschke at the University of the Arts Bremen. She is an active soloist and ensemble player, and also in charge of various orchestral, opera, and sacred music projects of the German Early and Late Baroque as an artistic director. As a soloist, she has performed across most of Europe, as well as in Japan, South America and USA. She teaches at the University of the Arts in Bremen. Her solo recordings of harpsichord works by JP Sweelinck, JJ Froberger, and English virginalists have earned excellent reviews in the music press and among their peers. Together with viol player Darius Stabinskas, Alina is the co-founder of the ensemble MORGAINE, which focuses on the music of the Polish-Lithuanian Commonwealth. In this conversation, we talk about her love for early music, playing harpsichord and Sigismundus Lauxmin International Harpsichord Contest which she organised the 2nd time this year. Relevant links: https://alinarotarumusic.wordpress.com http://www.bmfestival.lt http://www.bmfestival.lt/bmf2022/en/contest.html http://fontesmusicae.pl/notes-editions-c-series/ http://fontesmusicae.pl/szelest-en/
https://www.linkedin.com/in/kelsey-tempel/ (Kelsey Tempel) is a Senior Product Manager at https://www.sonos.com/en-us/home (Sonos), a wireless home sound system that fills your home with brilliant sound, room by room. Kelsey comes on the show to dive into all things product development like how to stay focused on your customer through the development process and how to find innovation even with an established product. She discusses what makes Sonos so unique and how they've adapted to significant changes like the prevalence of the cloud and covid. She highlights the importance of automation and rapid iteration in product update cycles and shares what skills she thinks make the best product developers successful. 1:09 - How Kelsey got into product development 6:40 - What makes Sonos different and innovative 11:50 - Best ways to identify customer pain points and evolve a product 12:55 - Impact of Covid at Sonos 15:20 - Role of automation and rapid iteration in product development 18:44 - How to keep innovation going as a product leader There's A Device For That is hosted by https://www.linkedin.com/in/sjvreddy/ (Sudhir Reddy), SVP of Engineering, of Esper. For more about Esper, visit us. https://blog.esper.io/ (Esper Blog) https://www.esper.io/ (Official Esper site) https://www.esper.io/book-a-demo (Book an Esper Demo)
"Montana (Main Theme)" by Blanck Mass from the soundtrack to Ted K; "Fields of Remembrance" by Plankton Wat from Hidden Path; "I Never Lose, Never Really" by Belong from October Language; "Major Beef" by The Party Dozen from The Real Work; The title track from Beat by Bowery Electric; "Le Palace" by Arp from New Pleasures; "Interstate" by Oog Bogo from Plastic; "A Year Ago" by Carmen Villain from CV x Actress; "A Breath of Fresh Air" by Scout Island from Laurentian Voyage; "Mindflight" by Flying Lotus from the soundtrack to Yasuke; "And Then I Watch It Fall Apart" by Madeleine Cocolas from Spectral; "Lineal" by J. Zunz from Del Aire.
Double T Mornings is the morning show on 96.7 The Eagle in Rockford, Illinois. Not only does Double T play Rockford's favorite Classic Rock each day, he's also joined by many fascinating guests including music legends, comedians, pro athletes, and his own stable of experts on random subjects. Plus, it's a local show, so he's all in for Rockford.
HBK Boom talks getting into music , playing college basketball & more
Hey Kings and Queens, this is a message for my single parents, y'all be encouraged!!! !! **I DO NOT OWNT THE RIGHTS TO THE MUSIC PLAYING!!*** Music Playing in background: Soaking In His Presence by William Augusto. Source: Youtube music.
2022 is music mania! There is so much music playing this year. That winter frost is finally thawed and with it comes a year of music, concerts, and festivals. In this episode, I'm talking about all the live music that I would love to check out this year. Get a full transcript of the show here. What live music are you looking forward to? This episode is sponsored by Anchor: The easiest way to make a podcast. https://anchor.fm/app --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/eat-sleep-breathe-music/message
Markus B Music stops by to chat with Uncle Vinny. Markus is the definition of "Versatile" as he shares his experiences as a drummer, producer, rapper, engineer, and more. We also discuss his upbringing in Parkdale, his interest in the Music Business, being a current Paralegal Student, "Toronto Artist Collective" and much more. Follow Markus @MarkusBMusic to keep up with new projects and performances! Check the following links to keep up with new Versatile Vigilante content: Website: https://versatilevigilante.com Instagram: https://www.instagram.com/VersatileVigilante/ Soundcloud: https://soundcloud.com/versatilevigilante Spotify: https://podcasters.spotify.com/podcast/6rbWSYZP9asHUv431qHZfK/overview Apple Podcasts: https://podcasts.apple.com/ca/podcast/versatile-vigilante/id1384221180?mt=2 SmartURL: https://smarturl.it/versatilevigilante
Vieques Beach ambiance w/ Latin music playing & waves crashing | Outdoor Beach Restaurant Ambience _____ Please subscribe for *DAILY* videos: https://bit.ly/3nKXe3u Link to video: https://youtu.be/C7AUfoC6RQQ ________ Get access to subscriber-only content: 1) 3-Hour episodes 2) Early access to new episodes 3) ** As part of your subscription, you can send us photos/videos of your pet and we'll feature them on the podcast cover art & in the YouTube video along with their name & cute little story subscription link: https://anchor.fm/soothing-soundzzz/subscribe Vieques Beach ambiance outdoor beach restaurant ambience Vieques Beach at night sound Vieques Beach music Latin Music Ambience Vieques Beach at night Vieques Beach ambience seaside cafe ambience outdoor cafe ambience ocean cafe ambience beach cafe ambience tropical music sea cafe ambience beach cafe night beach cafe night ambience beach cafe ambience at night sea cafe ambience at night ocean cafe ambience at night ocean cafe at night ambience sea cafe at night ambience beach cafe at night ambience beach restaurant ambience seaside restaurant ambience surfside restaurant ambience outdoor restaurant ambience _______ BEST 4 AROMAS TO GO WITH VIDEO If you'd like to try combining this audio with the best aroma, here are the 4 best scents for different moods... 1) BEST SCENT FOR SLEEPING, RELIEVING STRESS & ANXIETY *Lavender* https://amzn.to/3D5hIbL Lavender contains linalool that has anti-anxiety effects, but without the negative side effects of many medications. Studies show that the scent of lavender soothes you and helps you relax. It inhibits anxiety, depression -- some studies have shown that it even has a 20% 'better than average' increase on quality of sleep 2) BEST SCENT FOR RELAXING, FEELING GOOD *Vanilla* https://amzn.to/3E38IoW Vanilla oil's powerful aroma stimulates your brain to release endorphins -- Studies have shown that Vanilla fragrance makes you calmer 3) BEST SCENT FOR SHARPER FOCUS *Eucalyptus* https://amzn.to/3xD8pPl Sharp and highly pungent -- inhaling eucalyptus opens your sinuses and clears your head -- widely believed to decrease symptoms of stress -- In one study, 62 healthy people experienced significant reductions in pre-surgery anxiety after inhaling eucalyptus oil. Eucalyptus contains eucalyptol, which has been found to possess anti-anxiety properties 4) BEST SCENT FOR GENERAL ALERTNESS, CLARITY *Peppermint* https://amzn.to/3nZisen The smell of peppermint can mentally perk you up. _________________ SOOTHING SOUNDzzz ON SOCAL MEDIA: TikTok https://www.tiktok.com/@soothingsounds000?lang=en Instagram https://www.instagram.com/soothingsoundzzz/ Facebook https://www.facebook.com/Soothing-Soundzzz-271614694688828/ Spotify (Podcast) https://open.spotify.com/show/6vHMEcA5DQdriv4SBNePwe _________________ More Videos: - SUV Tent Camping in Heavy Rain w/ dimming & brightening candle | Car camping & sleet sounds -- https://youtu.be/Xjwf0-aFARY - Wind Chimes Ocean Waves
In the second of this two-part ASCO Education Podcast episode, Drs. Stephen Berns (University of Vermont), Tyler Johnson (Stanford Medicine), and Katie Stowers (Oregon Health & Science University) continue their discussion about what it takes to deliver serious news to people with cancer effectively and compassionately. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT [MUSIC PLAYING] STEVE BURNS: Hello, and welcome to the second part of ASCO's Education Podcast focused on clinician-patient communication in the context of delivering serious news to patients and families. My name is Steve Burns. I'm an internist, hospice, and palliative care physician and associate professor of medicine at the University of Vermont College of Medicine. Once again, I'm joined by Katie Stowers, a hospice and palliative care physician and assistant professor of medicine at the Oregon Health Science University, and Tyler Johnson, a medical oncologist and clinical assistant professor of medicine at Stanford University. In our previous episode, we spoke about what constitutes serious news, the best modalities for delivering serious news particularly in the wake of COVID, who might be the best person to deliver it, and the importance of the care team as a whole. We left off on the question, how do we prepare for delivering serious news? Let's continue the conversation. [MUSIC PLAYING] TYLER JOHNSON: Katie was talking about how we need to be realistic about the way that a conversation is going to impact us in addition to the way that it's going to impact the patient. And one thing that I have realized is that a headline, for those who maybe haven't had evals of training, is just a concise summary statement of sort of the big picture of what's going on, just like buying a newspaper article. And what I have recognized is that oftentimes, I have this almost visceral reaction against giving a headline. And if I drill down just a little bit, what I find is I don't want to give the headline because then I'm really going to have to say things the way that they are, right? If I give a five minute disquisition on creatinine and edema and chemotherapy, immunotherapy, therapeutic options and whatever, right? Then, I can just like talk a cloud around things and never actually say what it is that I'm trying to say, which then gives me the advantage of feeling like I said it, but actually sort of knowing that I never actually said it, right? And so I think the thing that the headline does is it forces me to say the thing. And then once the thing is out in the open, then we can talk about, if necessary and appropriate, some of the other nuances and whatever. But all of that is to say that often, the greatest barrier to doing that is an unwillingness to be real with myself about the information that I'm really trying to convey. KATIE STOWERS: I think this is another really great opportunity where when partners go in together, it's easier to get into the moment if you get the opportunity. Someone with a little bit of accountability, but also somebody to help you. Maybe you're able to get out the facts and they're able to tie-in the meaning. Or you end up going bigger than your headline and they're able to say, I think what you were trying to say was dah-dah-dah-dah-dah, and help really get back to that core. STEVE BURNS: It does say that we all, before we share serious news, making sure whoever you're going in with, you're on the same page. And having a pre-meeting is so important. And what I often do with my pre-meetings is I come up with the headline as the group, right? So we're all clear about what is that headline so that when we go in, we can, in some ways, also hold each other accountable for that headline. KATIE STOWERS: I think also, a little bit of who's going to say it too. Like, is that something that you feel comfortable saying, or would it be easier for somebody else to say? Are there parts of it, and then parts of it that I can do, I think, can be really helpful. TYLER JOHNSON: Yeah. It's funny, because sometimes, even though I'm pretty tuned into these things and I try really hard to do them well, I still find that there are times as a medical oncologist when the palliative care doctor who is unfailingly ever so nice and gracious about it, ends up being like the real human translator for my medical leads. So I, like, say some word cloud. And then the palliative care doctor, like Katie just said, is like, if I can say that what Dr. Johnson was trying to say right there is something in normal human English speak. And then, as soon as they do that, I'm like, oh. But that can actually be really helpful. And again, I think it's obviously not meant to slight me. It's not meant as an affront, right? It's just sometimes, it's just kind of hard to quite get there, right, and to quite say the thing. And sometimes, having someone to help. Like, you get 80% of the way there, and then having somebody else get the other 20% is really, really meaningful. And it also, in a strange way, kind of allows us to share the emotional burden a little bit, right? So that it doesn't feel like, oh my gosh, this is just me saying this thing. There's something about having other members of the team there to kind of hold your arms up as you're doing that that's really meaningful. KATIE STOWERS: I worry that part of this conversation is saying like, oh. Some people are really good at this. Some people aren't. I don't think that this is a palliative care physician's good the whole time. I think this is a normal human experience. This just happened to me. This week in clinic where my patient was like, you just told me like a five minute story of things I already know. And I still don't know any more information. And I was like, oh, that wasn't really clear at all, was it? So I mean, I think it's when our nerves pop up. When we are uncertain or unclear about what it is that we want to say or just really nervous about doing it, like, I think this is our normal human default to go back to beating around the bush. But it definitely, as Steve mentioned, is a skill that we can learn and continue to practice. And it's also really helpful to have somebody there who can hold your feet to the fire and help you in the moment. STEVE BURNS: Katie, I'm so glad you mentioned that. I just think about even for us as palliative care physicians, who do serious illness conversations all the time, catching ourselves doing some things because we are being affected by the conversation and our well-being. I remember a couple of weeks ago, how hard it was for me to say dying and death. And I know. I've been teaching my learners say the D word. It's OK. It's direct. It's straightforward. And then all of a sudden, I was in the middle of the conversation and I noticed I was struggling saying death. And so again, just to say we are human, that these conversations affect us. And having team support is so helpful in the moment. Because the chaplain who I was with said, what we're saying is we're worried that she's dying. And I was like, oh thank god. She said it. TYLER JOHNSON: And the other thing too, right, is that I think it's helpful in a sense to recognize that the difficulty with giving a headline or with saying death or dying or whatever is an impulse borne of human compassion. I mean, it's not because we're bad people. It's because we have good hearts and because short of maybe clergy members, there's really nobody else in the way that human ecosystems are set up that does this, right? It's just a hard thing to do. And recognizing that it's hard and recognizing that we ourselves are having a hard time with it, is not some failing of doctoring. I would say that actually, this is one of those weird instances where having that consistent struggle, that should be a tension that should define part of how we doctor. Because if the tension goes away, that's actually more worrisome than if the tension continues to be there, though we have to find productive ways to engage with it. STEVE BURNS: Yeah. We did a study in 2016, the Vermont Hospice Study, and similar to actually, what Cambia Health Foundation found, why people don't engage in serious illness conversations. And one of the biggest reasons was taking away hope or hurting people's feelings and in causing emotional distress. We also know with the literature that most patients, up to like 90%, 95%, want to know the truth because it helps them better make decisions. And I think we can deliver prognosis in a compassionate way. And I think practicing that in the kind and caring way that's person-centered, asking them, what do you know? Is it all right if we talk about this right now? Delivering in a headline and responding to emotion can help make that a more compassionate conversation. Although it still doesn't take away the human feeling that I'm worried I'm going to hurt someone in this conversation. TYLER JOHNSON: Almost always in my experience, patients who have metastatic disease, or for some other reason, disease that is known from the get-go to be incurable, in one of our first discussions, they will ask some version of the question of how long do I have, or what are things going to look like going down the road? There's good evidence to demonstrate, and it has also been my personal experience, that we're really bad at answering that question at the time of diagnosis, right? Because we don't know anything about the biology of the tumor, the response of chemotherapy, what the molecular markers are. There's a whole host of things that just make it so we almost always cannot answer the question accurately even if we try. And so what I will usually do is I will tell patients, I'll say, when they ask some version of that question, I'll say, look. I need you to know that, first of all, I can't answer that question right now. I'm not obfuscating. It's just, I would be lying if I gave you an answer because we just don't know. But I want to let you know that what is true is that I can usually tell when things are starting to go in the wrong direction. And unless you ask me specifically to do otherwise, I promise you, the patient, that as soon as I recognize that things are heading in a direction that I'm concerned about, I will tell you that in so many words so that you understand what I'm talking about. And then we will have a discussion about where to go from there. And then, when we get to that point, whether it's six weeks later or six months later, or sometimes six years later, I will say-- because I do this with all my patients-- I'll say, do you remember when I made you that promise way back when or a few months ago, whatever it is? And then I'll say, I hope that I'm wrong here. But I'm concerned that we may now be in that place. And I want to tell you why, and then I want to talk about where to go from there. Because that then situates this difficult discussion in the context of this relationship of trust that we've been building over however long I've known the patient. And I have found that that provides a trusting context within which to have the more difficult conversation that has been really helpful. STEVE BURNS: Noticing the time, I'm curious, how does the task of delivering bad news affect your own well-being? TYLER JOHNSON: Just to remind people, we said this before, but I just think it's important to recognize that this being a heavy thing is normal. And recognizing that is normal and that it really is-- I mean, there's some degree to which you can do this well and that will lighten the burden to some degree. But you have to make sure that you're filling your own reservoir, right? You can't pour empathy out of an empty reservoir. And so I think you have to make sure that you're filling that in whatever the ways are that you do. KATIE STOWERS: I just think I was thinking about that too, Steve. One other thing that I wanted to build off of, this fear and this worry that we bring to these conversations, that I'm going to send them into a tailspin of depression. Or I'm going to take away all of their hope. I think there is the other part of this that I get to see as a palliative care physician, which is the high degrees of distress that often come from not knowing this information, that's really helpful in preparing and planning for the future and almost this sense of relief. Even when it's unfavorable, even when it's not what they wanted to hear, there's a relief in knowing and being able to do something with it. So that limbo and uncertainty. the idea that something terrible is out there or they can't prepare for it can be really distressing. And so to some degree, we're helping to heal by being able to move into some planning. STEVE BURNS: Yeah, I totally agree that it's such an important thing to minimize the stress of uncertainty. And the other piece that I think about is these are really sacred moments where we can really connect with our patients, share the news, find out how they're doing with it, and then find out what really matters in their lives. I think that really helps be my north star when it comes to continuing the care that I'll provide for them in their families. TYLER JOHNSON: Yeah. You know, there's a really harrowing, in some ways, but beautiful moment. And many of you will probably have read the book Just Mercy, which is written by this lawyer who's fighting for justice, particularly racial justice, for people who have been unfairly treated by the justice system in the deep South. And there's this moment towards the end of the book where a person who he had been fighting for who was on death row has just finally been executed. And he goes home and sort of just collapses crying. And then he writes really beautifully about how this moment of sort of shared vulnerability, where he kind of recognized that the reason that this was so hard was because even though he was vulnerable and broken in different ways than the person who had just been executed, it was still sort of a shared sense of vulnerability. It was what made his work hard, but also what made his work beautiful. And I think that in a similar fashion, when we have these really difficult discussions, I think that while there is a real moral weight and difficulty to it, there is also just as you said, they also end up being some of the most meaningful, memorable, and beautiful moments. STEVE BURNS: As a clinician, what have you learned over the years regarding communication with patients that may help others navigate scenarios where they can deliver serious news? I was just on service with a trainee. The team was delivering serious news. It was serious news around lung cancer. And the team's like, this patient's just not getting it. And we tried to explain it over and over again. And they're not getting it. And then my trainee went in and attempted and said, yes. Here's your diagnosis. We're concerned it's incurable. And you likely will die in the next year or so. And the patient said, no. I'll be fine. So we hypothesized before going in the room with me, like, what it would be. And what it came out is maybe it's not they're not understanding it. Maybe it's emotion. So we went back in. And sure enough, my trainee did wonderful and responded to emotion and said. It must be really hard hearing this news. And the patient immediately got sad and said, I'm really scared. And we unpacked that a little bit. And when we left the room, he said to me, yeah. That was emotion. He totally gets it. He's just upset. And so I just want to reiterate the idea, sometimes, it's not that they're not understanding it. It's that it's a lot to process. And there's a lot of feelings behind it. KATIE STOWERS: Building on that, one of the things that I see happen a lot around emotion is the health system is not set for people to process and to come to terms with these hugely life things and life-altering things. There's not time for people to process what this means for their life to term and process that emotion. And we're constantly pushing. And sometimes it almost could feel like badgering, really trying to get a decision to come where, with some degree of autonomy and some degree of time, allowing them to really process. People, a lot of times, get to where they need to go. But it's a process of really being able to deal with. STEVE BURNS: Yeah. TYLER JOHNSON: Yeah, the only thing that I will add is that these conversations, when they need to happen, work best when I have been mindful of laying the groundwork for the conversation over the entire arc of the illness. Rather than thinking of, oh, this is the thing that I do right when someone is getting close to dying. Because if you've never laid the groundwork and then you try to have the discussion, then when the person is really, really sick and in the hospital or whatever, of course, there's still a better and a worse way to do that. But even the best conversation if it's that isolated incident, in my experience, is nowhere near as good as if we have been transparent and building trust and building a sort of a shared vocabulary with the patient over the course of the illness. So that then, when they get to having to have quote, "the discussion" unquote, it becomes just one part of this longer chain rather than an isolated happening. And that really gets to what I was saying earlier about the promise that I make my patients when they first ask that sort of big picture question. That even though I'm not in a good place to talk about it right then, that I promise them that when it comes time, I will talk with them about that with candor. That makes an enormous amount of difference. I know I had a trainee who was with me one time who was a continuity fellow with me and had heard me make that promise to a number of patients and the first time he was with that same patient when it came time to have that discussion. And I said, well, you remember that promise that I made the first time I met you? And he could, for the first time, see all of the dots connect over the arc of the illness. It was like, whoa. Like, there's just really this power that comes. But you have to have been building it piece by piece over time. STEVE BURNS: I think both of you are highlighting for me two reminders that I want to keep in mind every day when I'm delivering serious news. One is sort of having an agenda but being flexible with my agenda. And I remember during my training, one of my mentors said, keep your agenda out the door. Don't force your agenda on the patient, as Katie mentioned. And yet, have a plan and still go in with that plan. The other piece that Tyler, you're reminding me of, is the importance of the arc of the conversation and how continuity. Because we build off of conversations from visit to visit. And yet, sometimes, someone else is taking over for us or they end up in a hospital or they end up in a nursing home. And it reminds me how important documentation is to convey what happened in that encounter. What was said, what was the headline that was shared, how did the patient respond, and then what was the plan. And far too often, we usually just write the results of the conversation. TYLER JOHNSON: Yeah. One last thing that I want to put a specific plug in that I have found to be enormously important, I think all of us would agree that amidst all the conversations that we might have as part of taking care of a patient, this is the one where shared decision-making matters the most. And yet, if you ask most people, even experienced doctors, how do you engage in shared decision-making around this kind of question? That's really tricky, right? Because I think what often ends up happening is that we either default to being very prescriptive where we go in and say, well, you should do this or shouldn't do this. Or we default to being waiters with the menu. Like, well. OK, so would you like some intubation on the side of CPR? And so, I think that both of those models are equally problematic and that the tool, the specific tool that has helped me really learn about how to do shared decision-making and even provides the specific words, is what's called the Serious Illness Conversation Guide from the Ariadne group at Harvard, which is the group founded by Atul Gawande and his colleagues. And I think that that gives a very brief script which, I mean, you can literally almost just read. You can get a little card that you can carry in your pocket or whatever. And it gives-- and the entire conversation in most cases, takes maybe 10 or 12 minutes. But it gives you the point-by-point things to say and really allows you to meaningfully engage in shared decision-making so that you spend the first half of the conversation listening to the patient's priorities and values, and then the last maybe third of the conversation, using that to make meaningful recommendations. And so again, it's called the Serious Illness Conversation Guide. And I would really recommend to listeners that they look it up. STEVE BURNS: That's a really great segue to what training and resources are there for clinicians and oncology trainees to improve their communication skills. The three resources that I can think about are Vital Talk, the Serious Illness Conversation Program out of Harvard and Ariadne Labs, and then they have a rich program which is from the American Academy of Communication of Health Care. All three are different ways of approaching communication skills training. I always think about the Serious Illness Conversation Programs about raising the floor to make sure that we hit the basics. And then Vital Talk is if you want to flex your muscles or flex your skills when it comes to how do I respond to really intense emotion, or if someone's avoiding the conversation, what do I do? They train with raising the ceiling or their goals to raise the ceiling. And Vital Talk actually came out of oncology conversations first with OncoTalk almost 20 years ago. And really thinking about not didactic-based, but practice and skills-based training. And I certainly have found it rewarding and life-changing for me, where I could actually label the things that I do every day, give myself some feedback, and then teach my trainees. TYLER JOHNSON: And I will just add, as a medical oncologist who has both taken the Vital Talk course and now is trained and teaching Vital Talk courses, that this is not just for palliative care doctors. And I think that it is particularly-- I mean, you may not have the interest or passion to want to become a Vital Talk trainer, which is understandable if you're a medical oncologist, either a busy practice or a heavy research portfolio. But it's just to say that they offer 1 and 2 and various iterations of courses, depending on how intensely you want to study these things. But it's just to say that the skills that they teach are concrete. This is not some sort of head in the clouds theoretical exercise. I mean, they're taught very concrete skills that you can wake up the next morning and employ you in your practice. And that I think to a point that is often counterintuitive to us, I think that we are almost afraid, as oncologists, to know about this because we think, oh my gosh. I didn't have time to engage in these long discussions. There's no way. But my experience has actually been what this does at the end, is it actually makes you more efficient. I know that seems counterintuitive, but we spend so much time sort of beating around the bush around this stuff that we actually end up making ourselves take longer. And having really concrete skills for how to have these discussions can actually make your practice more efficient for things that otherwise can really eat up a lot of time. KATIE STOWERS: I do a lot of teaching in Vital Talk incentives. It sounds like both of you do as well. But the piece of feedback that I hear from trainees that come take courses-- and I do a lot with oncologists and oncology fellows as well-- is oh, these are the things that I've seen in conversations at work that I never had a name for. Like, you're putting a name on something that I've seen. And maybe I've done a couple of times, but I didn't know that I was doing it this way. And especially for my colleagues who are practicing providers who teach others, they really love having a name and a framework for being able to teach these skills to others. It's not some magic fairy dust that you either have or you don't. It's actually, here's a skill that I can pass on to you and you can practice. And I can watch for, and we can have some feedback about. And I have seen that being a really enjoyable part of doing this framework. We have that, right, for almost every other part of medicine. But because communication is something that's so innate and personal, that hasn't always been the case around communication. And so I really love that about Vital Talk, that they've taken these pieces and put names on them. Because this is how you give communication clearly, information clearly, is the headline. This is how you show someone that you care about them. These are empathic statements. And that's something that we can use as a third language when we're going into team meetings together or when we're teaching a trainee. STEVE BURNS: It's one of the most important skills that we do every day, and probably the most important procedure that we do on a regular basis in all of our fields. TYLER JOHNSON: And I think you can tell from the way that the three of us have discussed delivering a headline during this podcast, that this is not like a thing that we learned seven years ago and then just sort of left in a drawer somewhere, right? Like, this is something that we're actively thinking about as we actually take care of patients every day, which is to say that it really is very applicable. STEVE BURNS: I feel like that's the time for today. This has been a really great conversation. Thanks so much for both of your insights and participation in this episode of the ASCO Educational Podcast. KATIE STOWERS: Thanks for inviting us. It's been great to be here. TYLER JOHNSON: Thanks so much. It's been a pleasure. [MUSIC PLAYING] SPEAKER 1: Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive education center at Education.ASCO.org. SPEAKER 2: 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.
Hey King and Queens, I pray all is well with each of you!!!! Listen, GOD is speaking in this season, He that has an ear let him hear what the spirit of the Lord is saying!!!!! **I DO NOT OWNT THE RIGHTS TO THE MUSIC PLAYING!!*** Music Playing in background: Soaking In His Presence by William Augusto. Source: Youtube music.
Hey Kings and Queens, this is a word from the Lord, he that has an ear let him hear what the spirit of the Lord is saying!!!! **I DO NOT OWNT THE RIGHTS TO THE MUSIC PLAYING!!*** Music Playing in background: Soaking In His Presence by William Augusto. Source: Youtube music.
Hey Kings and Queens, its time to let GOD complete us!!!! Get a personal relationship with GOD, marry him; man or woman you need to be in covenant with GOD!! **I DO NOT OWNT THE RIGHTS TO THE MUSIC PLAYING!!*** Music Playing in background: Soaking In His Presence by William Augusto. Source: Youtube music.
My guest today is Dr Hane Aung Co-Founder of GroovSense - a leading global UK MusicTech company on a mission to automate the social music playing experiencevia their AI Music Selection App. In this episode, Dr Hane and I discuss the ins and outs of automating the social music playing experience. Using artificial emotionally intelligent technologiesto create the perfect playlist.Podcast or vlog: The Power of Audio + Science + AI with Jasmine Moradi (https://www.jasminemoradi.com, Spotify, Apple Music & Google Play)Soundbites:#1 Dr Hane Aung's career journey from breakdancer, to Behavioural Computer Scientist to the Co-Founding GrooveSense. #2 How GroovSense is combing Artificial Emotionally Intelligent technology to automatically analyse the mood of the party crowd as it changes. (12:50)#3 Now music fans around the world can create the perfect real-time ‘hosted' party playlist with GroovSense. (23:46)#4 The ABBA Journey - how GroovSense scientifically learns about the crowd (30:28)#5 The GroovSense DJ Dashboard helps DJs make the best music selections based on the crowd's tastes. (43:23)#6 How businesses such as restaurants, clubs and retail can utilize GroovSense to automatically measure the behaviour customer sentencing to maximize their in-store music. (49:05)#7 GroovSense App vs. Social Jukebox App (56:35)#8 Dr Hane Aung' predicting the future of real-time behavioural sensing technology and GroovSense. (1:01:39)Host:
In this Oncology, Etc. episode, Drs. Patrick Loehrer and David Johnson Speak with Drs. Lecia Sequist (Massachusetts General Hospital) and Melissa Dillmon (Harbin Clinic) on how ASCO's Leadership Development Program (LDP) has taken them down varying paths, as well as the ways it has influenced their lives, careers, and the lives of those around them. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: education.asco.org | Contact Us Air Date: 2/1/22 TRANSCRIPT [MUSIC PLAYING] PAT LOEHRER: Hi, I'm Pat Loehrer. I'm director of the Center of Global Oncology here at Indiana University. DAVID JOHNSON: And hello. My name is David Johnson. I'm at UT Southwestern in Dallas, Texas. So Pat, we've got a couple of really great guests today. PAT LOEHRER: Yeah. I'm really excited. I've been looking forward to this. DAVID JOHNSON: So have I. Listen. Before we get started, I have a book I want to recommend to you. This one I got over the holidays and just finished it recently. It's called The Doctors Blackwell by Janice Nimura. So as many of our listeners know, Elizabeth Blackwell was the first female physician in America. Her sister Emily also followed her into the medical profession. Nimura really writes, I think, a fascinating biography about both ladies, particularly Elizabeth. And one point she made, and I think it's interesting, it's not really clear why Elizabeth went into medicine. Certainly at the point that she did in the mid-1800s wasn't a profession of great reputation at that time. And, in fact, Nimura describes Elizabeth as, quote, "lacking a caring instinct," which I thought was an interesting characterization of the first female physician. And she indicated that she was hardly a feminist. She was actually opposed to Women's Suffrage, for example. According to Nimura, she became a doctor largely just to show that she could. And then, really, the rest of her career I won't give away. The subplot is really quite interesting. I think you would find it most interesting to recommend to you and our listeners who have a particular interest in medical history. PAT LOEHRER: Actually, I've ordered the book. I can't wait to read it. DAVID JOHNSON: Excellent. PAT LOEHRER: I got a book for Christmas, Lyrics by Paul McCartney. And I read through that. That's fascinating, actually. So 158 of his songs were detailed and the backgrounds for it. So that was kind of fun. We're excited today because we're going to talk to a couple of graduates of our Leadership Development Program. That was a program of ASCO that was conceived a little over a decade ago. It's been, to my mind, one of the best programs that ASCO has done. It has taken younger faculty and oncologists from around the country, and Dave and I were among the first leaders of the program as mentors. I think that was one of the bigger mistakes ASCO has ever done. But despite that, we have a lot of fun. There were 12 graduates each year. They all had projects they presented to the board of directors. There were, if you will, classes and lectures throughout the year on leadership. And they all had projects. And for me, it was the best three years of my life, I think, through ASCO. It was just a lot of fun. And part of it was getting to know a lot of people, including Melissa and Lecia, who are with us today. Lecia is a Professor of Medicine at Harvard and Mass General Hospital. She did her medical school at Harvard, residency at Brigham and Women's Hospital, fellowship at Dana-Farber. She is currently the co-leader of the Cancer Risk Prevention and Early Detection Program at Dana-Farber and director-- I think I want to hear more about this-- she's the director of the Center for Innovation in Early Cancer Detection at MGH. Melissa, she went to Converse College in Spartanburg, South Carolina, went to medical school at Wake Forest. Then did her internship and residency at UAB. She did her fellowship at UAB. And she now serves as the Chairman of the Department of Oncology and the Board of Directors at the Harbin Clinic. And we're so excited to have both of you here. DAVID JOHNSON: Yeah. Very much so. And why don't we get started by just getting a little background information. Melissa, let's start with you. Can you tell us a little bit about how you got into medicine and, more specifically, why did you choose oncology? MELISSA DILLMON: That's a great question. I was a political science major at a women's college in South Carolina and was destined for the State Department. And we used to have January terms. And I mistakenly got put with-- and I don't think it's a mistake-- former graduate of Emigre Medical School, who is a medical oncologist in Greenville, South Carolina, for a six-week term and fell in love with medicine, fell in love with the ministry that he provided to his patients, and followed him to Bowman Gray and went back years later and told him thank you for changing my life. So that's how I got interested in medicine. I come from a long line of accountants and engineers. There is no person in my family in medicine. PAT LOEHRER: I was an engineer. Some of the best people in life are engineers. DAVID JOHNSON: I didn't know you drove a train. [CHUCKLES] PAT LOEHRER: Eat your heart out. DAVID JOHNSON: So Melissa, before you leave, I actually grew up very close to where you practice. How did you end up in Rome, Georgia? MELISSA DILLMON: Well, my dad and his twin are proud graduates of Georgia Tech. So he found me a job. And I said, well, I'm grown up. I was going to stay on faculty at UAB but came to Rome, Georgia and really was excited about the multispecialty group that I ended up joining. There's about 250 of us now. And kind of had the feeling of a university but in a small town. Kind of best of both worlds. Neither of my two daughters have gone to Georgia Tech. One of them is at Georgia. Just won that national championship. But my third one, we're hoping maybe she'll be the one that goes to Georgia Tech. PAT LOEHRER: So you stayed up and watched the game. I have to ask this, right? MELISSA DILLMON: I did. I stayed up to the very end. PAT LOEHRER: And so who are cheering for? Alabama or Georgia? MELISSA DILLMON: Definitely Georgia. PAT LOEHRER: Interesting. Good. Good. DAVID JOHNSON: And Lecia, why don't you tell us about your background and how you got interested in oncology. And let us know if MGH has a football team. [CHUCKLES] LECIA SEQUIST: Oh, sure. Thanks for having me here. This is going to be a fun conversation. So I grew up in the Midwest, in Michigan. But I've been on the East Coast now for the majority of my life. And when I was a resident, I was actually in a primary care track residency program, because I thought I wanted to be a primary care physician. And I really liked the idea of sticking with people, getting to know them over long periods of time, and kind of standing by them through the highs and the lows of their lives. Well, I was finding out in residency that primary care wasn't really like that. That was for television shows. People change primary care doctors and move around so much, it's rare that you actually do get to take care of people for a long time, at least in a big city. And I also found that, for me, primary care was a lot of asking people to do things they didn't want to do-- exercise, lose weight, stop smoking, do this, do that. And I always felt that I was at odds with my patients or nagging them. And then, when I would be in the hospital on oncology rotations, trying that out, I really felt like I was allied with my patients and not nagging them or pushing them, but really here we were together against this fight against cancer. And cancer was what we were fighting together. And I just fell in love with that. So much to the disappointment of the residency program that was really trying to get people to go into primary care, I said, I've got to be a specialist. And here I am. PAT LOEHRER: It's interesting, though, that you do risk reduction and prevention. So you're back to telling patients to lose weight and exercise again, you know? [CHUCKLES] LECIA SEQUIST: Yeah. I guess, in some ways that's true, although I'm not really taking care of primary care patients. But after spending a lot of years doing a more traditional medical oncology track of drug development and targeted therapies, the last five years I have switched my research over, kind of a midlife crisis situation, where I said I've got to do something different. I'm in a rut. And I started looking at new technologies for early detection. And I really enjoyed it because it's something different. For one thing, I just felt like I was in a rut. But it's really a way to be a lot more proactive with the community and to work on issues of social justice, thinking about cancer screening, and who has access and who doesn't, and what can we do better. So I'm really enjoying that in this phase of my career. PAT LOEHRER: Terrific. The four of us are linked because of this Leadership Development Program that the American Society of Clinical Oncology put together. And I think Dave and I are really curious whether, here it is many years later now. It's been almost 9 or 10 years later now. As you reflect on the LDP, what are some of the highlights? What did you learn about yourselves and was the program worthwhile for you? MELISSA DILLMON: Well, I'll start. I was part of the class, 2010-2011, best class ever. And it was the second class in the Leadership Development Program. I applied for the first year's class and didn't get it. And one of my friends and partners, a radiation oncologist, who was very involved in ASCO, encouraged me strongly. Said, don't give up. Try again. And I did. And it was instrumental in developing both my career within ASCO as well as pushing me to leadership positions in my own clinic and in my own state. And helped develop a lot of skills that have made me successful in pushing state legislative efforts. My political science background did not go away, just like her primary care roots. And so I think that the program also made friends with Pat and with Dave and with my co-classmates. And as the years have gone by, and I've gone to ASCO, when you see that LDP ribbon on somebody's tag, you immediately have a connection with them and know that you've been through a similar experience. So I think it's been really instrumental in developing my career. And I'm currently serving as a mentor for the leadership program. So I'm living your life 10 years ago, Pat and Dave, and it's great. DAVID JOHNSON: Oh, I'm sorry. PAT LOEHRER: Terrific. DAVID JOHNSON: [INAUDIBLE] LECIA SEQUIST: I would echo what Missy was saying about how much it's influenced my career. I was in the 2011 class. So I think the year after she was. And I also applied multiple times, and I always tell people who are thinking of applying that it often does take multiple attempts to get in and not to lose faith. The selection committee does like to see that persistence. So definitely apply more than once. I learned so much about what leadership is. I thought it was about being the best in a group of people. So then, being selected to have a certain title. And I just really learned so much during that year, that it doesn't really have anything to do with a title, although that can be a part of it for some people. But it's just more about a style, an approach to your profession, and that you can be a leader if you are the designated head or chief of something, but you can also be a leader if you don't have that designation. And there are many different styles and ways to lead and to help people to ultimately get a group to do the very best that they all can together. And the friends that I made that year from my co-classmates as well as you guys and Jamie, who are our leaders, are just lifelong friends and mentors. And you know, I think it really got me thinking seriously about my choices in my career too and not to just kind of cruise through a career and see what happened and where life took you, but to really plan and to chart your own course and to make sure to reevaluate. And if it's not going the way you want it to, to rechart and replan. DAVID JOHNSON: We had a bunch of different lectures on different topics. Was there one of the lectures or areas that was particularly beneficial to you? PAT LOEHRER: I can think of one. I'll start out by doing this. We threw this in the second year, just for the heck of it. We did this personality testing. And I thought it was fascinating because, in my group, there was a little bit of conflict going on with one of the people in my group. And I realized that we were both acting out our personalities. I like to look at the big picture, and he liked to just zoom in the middle one. And the other thing that I do remember is that we showed the profiles, and it turned out Dave and I were exactly opposite. And then we both said at the same time, we should be married. [CHUCKLES] MELISSA DILLMON: One lesson that stands out in my mind was the press preparation lesson that we received from Press Relations group at ASCO. And I think that was essential for developing skills with regards to preparing for difficult conversations and being able to redirect questions that were difficult. I use that as leader of the Government Relations Committee oftentimes. I will also say that the other lesson that stands out in my mind is conflict resolution because, at the time, I was not chair of my department and was having significant conflicts with the current chair of my department. And that lesson helped me to go back week after week and more constructively work towards a solution and then eventually became chair of that department. So I think those two lessons gave me lifelong skills that I've used in all my leadership roles. LECIA SEQUIST: Yes, it's amazing how 10 years later, we can still remember the specific lectures and specific comments that people made. I remember those that you were talking about Melissa, but yeah, before you had said yours, Pat, I was going to say the same thing, that personality test was extremely helpful. And I certainly don't remember all of the different initials of the personality types. But just to understand that concept that people have different emotional skills and blind spots that very much influence how they deal with others in the workplace. And to be able to think about that when you're having conflict with someone and think about how to take that into a strategy where you can kind of play to their strengths and understand where they're coming from, that was extremely helpful. And then, I also think that talking in small groups with our teams about specific problems we were having or obstacles that we were facing and getting advice from others on how to overcome them, that really started me on a recurrent mission to find friends who I could share that with outside of my institution, over the course of my career. I think that was a real exercise in how valuable that could be. It's so critical to have peer mentors that you can talk to and strategize with and get advice about how to handle something that you're struggling with at work and have people that aren't in the same room full of people or aren't living in it. So they're a little bit more objective. DAVID JOHNSON: Let me ask a question of the two of you. Do you think your home institutions in your case, Lecia, MGH and in your case, Missy, Harbin Clinic, valued that training that you received? Did they recognize it as something that was worth the time that you spent or do you think it just something that happened and they didn't really take notice? MELISSA DILLMON: I learned in LDP that institutions don't love you back. PAT LOEHRER: They don't love you to begin with. Joe Simone. Joe Simone. DAVID JOHNSON: So I take that as a no. Your institution really said, eh, OK, great. We're glad you did it, but so what? LECIA SEQUIST: I wouldn't say that. I don't know that they said, so what? I just, I'm not sure that they-- there was no rolling out the red carpet, thank goodness you did this. But I do think it's had an institutional impact in that I have since encouraged other people to apply from my institution. And I think that only strengthens the institution, to have multiple people going through that program. MELISSA DILLMON: So my clinic, being private practice, when I take time out, it is just a cut from my salary. There's no support given from the institution. But in order to be in positions of leadership, department chair or on the board of directors, which I later was elected to of the clinic, you have to have completed a leadership development program. And the clinic will pay for you to go do those things. But my participation in Leadership Development Program met all those criteria. So my clinic highly values professional development classes or meetings or programs and encourages that. Even if there's no financial support necessarily, it is encouraged, if you want to assume positions of leadership within our clinic. And so I think that it's important for institutions, whether they're private practice or university, to recognize the benefits that come from participation in a program like this. And it was interesting as a mentor this year, we did a personality test, but this time they did an interesting look at what our priorities, our top five priorities or values are. I think it was values. And it was a list of 300 things basically you go through. And you listed your top five values. And then you listed the values of your institution or employer. And then you wanted to look at, did they match? And did your university value what you value? And that was a really interesting exercise to go through because a lot of these young leaders who are taking their time out to do this program did not feel that support necessarily for them seeking out this program. PAT LOEHRER: It's no coincidence that Dave and I asked both of you to join because you both come from different places, if you will. And I think, Melissa, you've just been a rock star in terms of the community practices and so many things that you have done in the leadership roles. And Melissa's, you can't get any more prestigious in being in one of the Boston medical schools and particularly at Mass General. But the other reason we wanted to have you come in is to talk a little bit about your perspective as women and women in leadership roles. And if you could maybe share a little bit about your thoughts and perspectives of gender leadership and what you have noticed in men in leadership roles and women and what lessons you might give to other people, particularly other women in this capacity. MELISSA DILLMON: Well, I think we both were trained in a day. And I might be speaking for you, but when there were, at least here at the institutions where I trained, not that many women in internal medicine. Medical school was probably 45% female by the time I was in medical school. But when you look at the faculty of those medical schools that I went to and trained at, there were very few women in positions of leadership. And so there weren't very many role models. My dean of students at Wake Forest was a female nephrologist. And so she was a huge role model for me. And then I went to UAB, and I remember being asked in my interview, are you OK with being in a male-dominated program? Because you will be in a male-dominated program. I think there were 45 of us in my intern class, and eight of us were female. And I said, that's fine. But I had gone to a women's college, where obviously there were only women leading. So it was a big change for me to go back into a situation where I had to assert my unique female leadership qualities, which are different, and still use those in an effective way to lead. Right now, I'm serving as a mentor also for a small liberal arts college, primarily those interested in going into medicine or nursing, and usually most of those have been female. And so it's been a really great opportunity, because I've had very few mentors who were female, who were positive role models for me. So I think Leadership Development Program, one of the things they taught me was to go back and say thank you to your leaders and to be a leader for others. And specifically, as a female leader, I think that has been an important call for me. After leaving Leadership Development Program, I went back and ran for the board of my clinic as the first female to be on my board. My clinic was started in the 1860s, I think right after the Civil War, and I'm still the only female on that board. And I feel that it's important for me to stay there or to promote up more females within my clinic to be on that board because I think that having a diverse board helps in bringing different skill sets to the table. So I think Leadership Development Program gave me that courage to step up. LECIA SEQUIST: That's inspiring. Congratulations on being the first woman and may there be more soon. Yeah. I don't know that I've felt that I was in as much of a male-dominated field up in Boston. But certainly, leadership in my hospital and in my cancer center has been more male-dominated. And I think as I'm getting older now, I definitely appreciate-- of course, every individual has different leadership style. So you can't just paint a broad brush and say men are this type of leader and women are that type of leader. Everyone's a little bit different. But in general, I think women do tend to have a different leadership style and one that is maybe, present company not included, one that's less talking and more listening. And I think, when I was younger and trying to become a leader, I really felt out of peer pressure that I needed to talk more and sort of demonstrate more what a good leader I could be or what great thoughts I had. And I've really come to embrace a more listening type of leadership, which I have been happy to say that younger women that I work with have come up to me privately and thanked me for. And so I do think it's important to have all different types of role models for our junior faculty and all different types of styles, sort of on display and doing their best so that people can find something that matches with their own unique style to emulate. PAT LOEHRER: One of the lessons I learned a long time ago from someone, and I loved it, a great leader is one that changes the conversation. And to your point of listening, but it's really changing the conversation, deflecting it around it so that other people are talking. But you have a little role in moving that around. And I always liked that. MELISSA DILLMON: Today, I was listening to the National Press Conference, and I heard a definition of leadership that disturbed me. And I thought, I don't think that's my definition of leadership. So I think that defining what your type of leadership style is, is something that leadership development helped me with. And then, once I knew what my leadership style was, then using those skills to pull together a team and achieve a goal, a common goal, not the description of leadership today, which was pushing something up a mountain and rolling over boulders and doing whatever you had to do to get your way. I thought, well, that's not leadership, not my leadership. So I think that that was something that Leadership Development Program help me do is identify what my leadership style is and what kind of leader I want to be. DAVID JOHNSON: So I want to follow up on a point that both of you are making in a slightly different way. And that is, who are your role models? I mean, apart from Pat and me, but who are your role models? [CHUCKLES] LECIA SEQUIST: I've had lots of role models over the years, and I think at the beginning, my role models were really people that I wanted to emulate and be just like them. And that probably started with Tom Lynch, who was my initial research mentor when I started in lung cancer. And a lot of it was just the way he was with patients. I wanted to have that ability to make a patient feel just right at home from the first minute they walked in the door, which Tom is a master at. But over time, I think my mentors or my heroes have more become people that are different than me. And I'm not trying to be like them. But I appreciate the ways in which they lead or in which they conduct something, like balancing their home life and their professional life in a way that's just different but I appreciate. And that, in lung cancer, I would say another real big influence on my career has been Heather Wakely. She really has been my main female role model in my career. And she's given so much of her time to me and to so many to kind of sit and have personal talks and pep talks and strategies about what we're doing in our home institutions. DAVID JOHNSON: Missy, what about you? MELISSA DILLMON: So I would say from a professional standpoint, someone I respect and see as a mentor is actually now the female CEO of my clinic, who has been with my clinic for 20 years and worked her way up. And I think that's because she has retained her femininity, but she is recognized as a tiger that no hospital or other clinic wants to make mad. So she has a way of leading and listening that is unique. And I have learned a lot from her over the years and watched her rise in her leadership skills as I have alongside of her. And then, I will say from a personal perspective, one of the books I have enjoyed reading recently really talks a lot about servant leadership. And so I've really tried to identify servant leaders in my community and why it is that they're able to weather the storms of the last couple of years, for instance, and why their teams rally behind them and support them. And they're successful. And my husband is a restaurant owner times three, opening two of those, one right before COVID and one during COVID and yet has been able to mobilize a team. And that's because he's a servant leader that will get back in the kitchen and make pastry cream if that's what needs to be done or make reservations. And so I think during the last two years, what I have learned from that is to be a servant leader in the tough times has really helped rally my team and my clinic to be better and to continue to work, despite the challenges for our patients, for the bigger goal. PAT LOEHRER: Love it. We recently had a guy give a talk here at IU, and the lecture was on being a visionary leader. And to be honest, it was fine. It was good, but being a servant leader and being part of a group is more important than being the one right up in front. And it's good to be a follower too as a leader. So I really appreciate those comments. Just in a couple of sentences, I don't know if you guys could do this and reflect a little bit about your younger self. Say you're 21, and you could give yourself some advice now, what would those pieces of advice be? LECIA SEQUIST: I think one thing, and that's the common thread I've heard among a lot of more senior people in medicine, or in any profession probably, is that the things that you think are disappointments at the time often turn out to be some of the greatest opportunities that you're faced with. You plan and you think things are going to go a certain way, and then something doesn't work out, and you're very disappointed. But it's usually that process of how you deal with that disappointment that actually brings so much opportunity back to you. You can't see it at the moment. All you see is the disappointment. But I think that's a big lesson. PAT LOEHRER: Terrific. MELISSA DILLMON: So kind of similar to that, Lecia, doing our personality test this time, I wish I had done that same exact test 10 years ago, because I'd like to see what my leadership personality was 10 years ago versus now. I would not have scored as high in certain areas that I think I do now. And I think that one of the biggest things I have learned is, I'm very much a person of tradition. And I like things to continue the way I expect them, and I like things to be planned and done in medical school in four years, done with fellowship. So I like a regimen and a routine. And I have learned over the years to be comfortable with change. And I wish I had learned that earlier and to be open to change and listening to new ideas. I think that probably for the first few years of my practice and training, I was very much, this is the way it's done. And I think that that expressive part of my leadership had not developed yet. And I think that being open to change and looking at things in new ways, I wish I had learned that earlier. DAVID JOHNSON: So we only have a few minutes left. And what we have done in previous episodes, we like to ask our guests to tell us the book they've read recently or maybe a documentary or something they've watched recently that they would recommend to our listeners. LECIA SEQUIST: I really enjoyed the book The Four Winds by Kristin Hannah. That is a historical fiction about the Great Depression and the Dust Bowl and the migration of farmers from the Central Plains out to the West. And it was a really captivating book with a female protagonist. I enjoyed it quite a bit. MELISSA DILLMON: It's funny. I read that one just a few months ago. I love historical fiction, but I would say recently, and I know it's not a new book, Andre Agassi's Open, his autobiography, I found fascinating. I love sports, but it was very interesting to me to see how someone who's thrown into the limelight at a very early age and the pressure put on him by his parents and how that affected the course of his life. I found it a fascinating book and very insightful. And I like to play tennis, but I'm not a tennis player. But I found it interesting as a parent, who's got several sports-minded children, it gave me some lessons about parenting and how to just raise your children and where the focus should be. DAVID JOHNSON: Both my wife and daughter had been tennis players. I'm sure they would both love reading that book. Thanks for that recommendation. LECIA SEQUIST: It's a great book. DAVID JOHNSON: Well, that's really all the time we have for today. And Pat and I want to thank both of you, Missy and Lecia, for joining us. It's been a terrific conversation. Thank you so much for what you do. You're both, in our minds, fantastic leaders. You were when you arrived, and you certainly have been ever since. So thanks so much for that. I want to thank all of our listeners for tuning in. This is Oncology, Et Cetera an ASCO Educational Podcast. And we really have talked about anything and everything. And we'd like to continue to do so. So if you have an idea for a topic or a guest, please email us at education@asco.org. Thanks again for tuning in. And Pat, I just wanted you know I've ordered a chicken and an egg from Amazon. [CHUCKLES] PAT LOEHRER: It's because you couldn't quite make up your mind which was going to come first. I love it. I love it. You're the best. Thanks for doing this. And Dave, it's good to see you, as always. Take care. DAVID JOHNSON: Thank you so much. We really, really appreciate it. LECIA SEQUIST: Thank you. MELISSA DILLMON: Great to speak with you. Bye. [MUSIC PLAYING] SPEAKER 1: Thank you for listening to this week's episode. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org. [MUSIC PLAYING] 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. [MUSIC PLAYING]
How do you talk to patients about medicinal cannabis? Dr. Ashley Glode (University of Colorado) moderates a discussion on effectiveness and safety, misconceptions and more. Featuring Drs. Ilana Braun (Dana-Farber Cancer Institute), Daniel Bowles (University of Colorado), and Kent Hutchison (University of Colorado). Subscribe: Apple Podcasts, Google Podcasts | Additional resources: education.asco.org | Contact Us Air Date: 1/19/22 TRANSCRIPT ASHLEY GLODE: Hello, and welcome to ASCO Education's podcast on medical cannabis, also referred to as medical marijuana. My name is Ashley Glode, and I am an associate professor with the University of Colorado School of Pharmacy. It's my pleasure to introduce our three guest speakers Dr. Ilana Braun is chief of the division of adult psychosocial oncology at Dana-Farber Cancer Institute, and an assistant professor of psychiatry at Harvard Medical School. Dr. Daniel Bowles is an associate professor of Medical Oncology at the University of Colorado. We're also joined by Dr. Kent Hutchison, a professor of psychology and neuroscience at the University of Colorado Institute of Cognitive Science. Let's start with a simple but fundamental question. What is medical cannabis or medical marijuana? ILANA BRAUN: So Ashley, I think that's such a great first question. I think of medicinal cannabis as herbal nonpharmaceutical cannabis products that patients use for medicinal purposes. And typically they're recommended by a physician in compliance with state law. DANIEL BOWLES: Dr. Braun makes a really good point. And I think it's important to know when patients are referring to medical cannabis, there's a wide variety of different things they could be referring to. Sometimes they would be referring to smoked herbal products, but there are also edibles, tinctures, ointments, creams, all sorts of herbal-based products that people use and call medical cannabis. And then there are also the components that make up medical cannabis-- largely, the cannabinoids. And I think the big ones people think about are THC and CBD. And sometimes those are used in their own special way. So I think that it's important for us as providers to be able to ask our patients, what is it that you mean when you say, I'm using medical cannabis? ILANA BRAUN: I think that's such a great point. And I will add I think it's also important to remember that when you offer a medicinal cannabis card to a patient, you're giving them license in most states to access any number of products. It's not an insurmountable challenge, but it's a whole new world for traditional prescribers who are used to writing a prescription and defining what is the active ingredient, how often a patient will take the medicine, by what means. DANIEL BOWLES: I think the other thing we need to be very aware of, as hopefully people are listening to this across the country and elsewhere, is the laws vary wildly from jurisdiction to jurisdiction about what consists of medical cannabis, who is allowed to use it, and in what quantities. So I think it's really important that as we learn about these and we think about these, we think about how they apply to any of our specific situations in which we live in practice. KENT HUTCHISON: So it's interesting-- just follow up on what Dr. Braun and Dr. Bowles, what they're saying, those two words-- right-- medical and cannabis. I think the medical part is somewhat easier because it can refer to the reason the person is using. Are they using for medical reasons are they using for recreational reasons, even though that's a blur? But the cannabis part I think is what's really complicated. And this is what Dan was getting at. All the different products, all the different cannabinoids, I mean all the different bioactive terpenes and everything else in the material, all different forms of administration. That is where it gets super complicated to really define what that is. And then of course, there's so little research we don't really know what all those constituents do. ASHLEY GLODE: Now that we kind of have a little bit of familiarity with medical cannabis, can you comment on adult use cannabis and what that might mean for a patient? ILANA BRAUN: Ashley, I think it's a really good question. And in some of the early research I did to try to understand where medicinal ended and adult use began, or adult use ended and medicinal began, I began to discover a theme that emerged, which is they sort of blend into each other often. In other words, some of the oncologists that I spoke to believed that it was not such a bad thing for a patient with serious illness, and pain, and many other symptoms to have a sense of high or well-being. And conversely, when I spoke to patients using cannabis, sometimes a cancer patient used medicinal cannabis for enjoyment, and sometimes they used it for symptom management, and sometimes they used it for both. And so I think it is somewhat of a slippery slope between the two. Would you agree? DANIEL BOWLES: I think there are definitely blurred lines between the two. I think that the advantages of what most states would recognize as medicinal cannabis is usually they're less expensive, patients can use them in larger quantities. There are certain advantages. But there's also paperwork that goes along with medicinal cannabis that some patients don't feel comfortable with. Or particularly I think when you have a patient who's interested in trying cannabis or a cannabinoid for the first time, they might not want to go through all the extra steps required getting that medical marijuana card, whereas adult use, I think people feel more comfortable, at least in my state, sometimes walking into a dispensary to discuss the options with people who work at the dispensary and then get it from more of an adult use or recreational cannabis initially. And then if that's something that they find helpful for their symptom management, to then take those extra steps and try to get a medicinal card. ILANA BRAUN: I agree with Dr. Bowles that the target symptoms or the target effect is often similar and access can differ. KENT HUTCHISON: Yeah. Just to chime in, I agree. I agree also. It's definitely-- the lines get blurred. The recreational user might also appreciate-- for example, college students, I hear them say a lot of times that they appreciate some of the anxiety-reducing aspects-- right-- even though they're not necessarily a person who has an anxiety disorder. And then of course, patients appreciate a slight increase in euphoria or positive affect, and what does that mean? Is I mean they're also using for recreational reasons? Or is that completely, I guess, legitimate? On the other hand, there are sometimes I feel like when-- especially on the recreational side-- when people are using for the more psychological effects, the sort of psychotropic effects, I know sometimes the medical patients refer to that as being a little bit loopy as a side effect. So I feel like there's definitely some blurred lines. And maybe there are some places where we can think about in perhaps in a less blurred kind of way. ASHLEY GLODE: How often do you guys have a patient ask you about medical cannabis? And what are the most common questions they might have for you? ILANA BRAUN: In my psycho-oncology practice, patients frequently tell me they're using cannabis, often with good effect and minimal side effects for polysymptom management-- for instance to address nausea, or pain, or poor appetite, or sleep, or mood, or quality of life. But they don't ask me a lot of questions. For instance, one of my longest-standing patients. A man with metastatic cancer and gastroparesis. Vaporizes cannabis before meals to keep his weight up. And many of my patients also use cannabis as cancer-directed therapy. And for these patients, side effects can sometimes be more pronounced. For instance, I have a lovely patient with metastatic cancer who follows a Rick Simpson protocol. So what is that? That's an online recipe marketed with an antineoplastic claim. And so this patient targets hundreds milligrams of cannabinoids daily. And with such high cannabinoid doses, she sometimes feels spicy, or out of it, as she describes it. And then I had another patient who targeted high daily doses and developed a debilitating nausea and vomiting that was initially diagnosed as chemotherapy-induced nausea vomiting because it was so hard to tease out in the setting of so many medicinal agents, what was what. But the symptoms resolved completely within weeks of the cannabinoids being halted. And so as I mentioned, what's notable about all three of these patients, and many of the others I see, is that they are quite open with their oncology teams and me about their medicinal cannabis use. But they don't seem to rely me or other members of their oncology team for their therapeutic advice . We insert ourselves when we see potential harm, but much of the decision-making seems to be made-- I don't know in the naturopath's office, at the dispensary counter, or by trial and error. And this anecdotal experience in my practice is borne out in my research findings as well. Patients are just not getting the bulk of their cannabis therapeutics information from their medical teams. DANIEL BOWLES: In my clinical practice, I am asked about cannabis or cannabinoids a fair, amount often in the context that Dr. Braun is describing, where a patient is coming in and they're already using a cannabinoid or they are planning on doing it and they just want my opinion. And I think unlike talking about more conventional cancer-directed therapies where they really rely, I think, on their medical team for information and guidance, we are often more a supplement I think in terms of information. In terms of the patients who come to ask me about cannabis or let me know that they're using cannabis, it's a very wide selection of people. I see young people, old people talking about it, men, women, a variety of different malignancies. So there really is a lot of usage or are thought about usage of cannabis or cannabinoids amongst our cancer patients. I think if you look at the studies, they'll tell us that depending on where we're working, anywhere between 20% to 60% of patients have used cannabis in the last year to help manage some sort of cancer-related symptoms. And I think the other thing that is notable is you'll find people asking about cannabis or cannabinoids who I think we might not have otherwise expected. So for instance, Just this past week, I had a patient with anaplastic thyroid cancer in his 70s, and his daughter was wondering whether he could try CBD to help with his sleep and anxiety. She wanted to make sure that it wasn't going to interact with this cancer therapies. And I appreciated her bringing it up, and we could have a frank discussion about the pluses and minuses of it, just like we might any other therapeutic intervention. So I think that particularly as the laws have changed across the country, more and more people are willing to tell us that they're trying cannabinoids and cannabis than maybe would have even 10 or 15 years ago. KENT HUTCHISON: I think in an ideal world, patients would be talking a lot more with their physicians about this topic. And I think unfortunately that a lot of people do get their information from dispensaries. From the media, from social media, from their kids, and from whoever. And I think that's something that I hope will change in the future. DANIEL BOWLES: In terms of questions that I'm often asked, I'll be asked if it's going to interact with their cancer treatments, in terms of making their medications more or less effective. I do get questions about how I think their cannabis use might affect some of their symptoms. I get questions about other drug-drug interactions-- let's say, interactions with opiates, or benzodiazepines, or some of these other medications that a lot of our patients are on. ASHLEY GLODE: In a recent survey 80% of medical oncologists who discussed medical cannabis with their patients, 50% recommended it in the past year, but only 30% felt knowledgeable enough to make recommendations. What do you guys think needs to be done to address this knowledge gap? And what resources do clinicians have to get and stay informed? DANIEL BOWLES: So I'm a big fan of the NCI's PDQ as a great resource. It has a fairly objective information about cannabis and cancer specifically. So I think that's a nice reference for people who are interested in getting an initial overview on the topic. I think there are also a number of different educational programs. I know the University of Colorado, for instance, has a Cannabis Science Master's and also a certificate program. So there are courses available for people who want to educate themselves more on this topic. ILANA BRAUN: Yeah. I guess when I think about what needs to be done, I think that cannabis needs to become a routine part of medical training curricula and CME programs. I think that a federal funding for high-quality clinical trials and a loosening of federal restrictions on accessing study drug were to occur, that would be really a big boon for the medical community. And my colleagues on this podcast I know are doing some very creative pragmatic clinical trials naturalistic studying what is happening in the field. And I am doing clinical trials using an FDA-approved version of cannabinoids. But it's still very hard to study whole-plant cannabis in a form that is sort of a standardized trial drug in a cancer patient. And then when I think about where I would begin to read, I don't think there is a single source, unfortunately. But a great place to start reading is actually a project that Dr. Hutchinson was a part of, which was an expert panel that was assembled by the National Institute of Science Engineering and Medicine in 2017. And they produced a monograph on the health effects of cannabis and cannabinoids. And it's several hundred pages long, including sections devoted just to oncology. So in other words, there is scientific evidence to evaluate, and it's sizable. DANIEL BOWLES: The Austrian Center for Cannabinoid Clinical and Research Excellence also is a helpful resource. One of the nice things about that is they actually give some dosing suggestions or ideas for people who really don't quite know where to start. Right now, there aren't a lot of people in that position to say, here's how it should be done. Here's how it gets dosed. Here are the data to support those decisions. And so the folks in the next level of training don't learn it in the same way that we have learned how to prescribe other medications. And they can't then lay it down. So because the data are scant, in some respects, and particularly for herbal products that So. Many of our patients are using, I think it falls outside the medical model that we've all become so used to using to learn how to take care of patients. And I think that's one reason that so many oncology providers feel interested in learning more about this topic, but don't feel comfortable giving patients guidance on how to use them. KENT HUTCHISON: So both Dr. Braun and Dr. Bowles identified some of the key resources out there. And certainly the training issues that Dr. Bowles just talked about are important. And I do want to emphasize the one thing that Dr. Braun mentioned, which is basically that we do-- we lack research and we lack data on some key important issues, like dosing, for example. What dose is effective? So cannabidiol has been out there for a long time, but what dose is effective for what? We don't know, right? So we definitely lack research. And there are definitely obstacles to doing that research. ASHLEY GLODE: So you guys brought up some good points about there being a lack of data, but also there is some evidence. So what is the current research and evidence on the efficacy of medical cannabis for management of cancer symptoms and cancer pain, specifically? DANIEL BOWLES: So there was a really nice review article that just came out in the BMJ looking at cannabis and cannabinoids, not specific to cancer pain, but including cancer pain. And what they found-- they looked at different preparations from herbal products-- smoked herbal products, oral agents-- cannabinoids, more specifically. They found there is a modest, but a real improvement in pain in patients or research subjects treated with cannabinoids versus those usually typically treated with placebo. In particular, the data are supported in neuropathic pain, I'd say more so than the other pains. I think the data are less compelling with regards to many of the other symptoms that people often use cannabinoids for, such as sleep, anxiety, appetite, things along those lines. ILANA BRAUN: So I'll tell you a little bit about how I think about the evidence base in oncology for cannabis use. So I'll preface this with two points. The first is that, as I mentioned, cannabis products tend not to be one active ingredient, but hundreds of active ingredients-- cannabinoids, phenols, terpenes, they all have bioactivity. And they don't work individually, they work through complicated synergistic and inhibitory interactions that have been termed entourage effects. So I don't think one can easily extrapolate from clinical trials of, say, purified THC, to understand whole-plant cannabis' activity in the body and how it might perform in humans. And then the other point I'll make is that when I think about the types of clinical evidence that we as clinicians hold dearest, it's clinical trials of our agent of interest in our population of interest. So cancer patients using whole-plant full-spectrum cannabis that they would access at a dispensary or grow in their own home. With this in mind, I believe the strongest evidence, randomized double-blind placebo controlled trials of whole-plant cannabis and oncology populations begins to support its utility for chemotherapy-induced nausea and vomiting. So there have been a few studies that have looked at this. But just in 2020, the most recent is a study by Grimison, et al. It was a multicenter randomized double-blind placebo controlled crossover trial comparing cannabis extract. And I think the extract they use was a 1 to 1 THC to CBD ratio versus a placebo in patients with refractory chemotherapy-induced nausea and vomiting. And what they found was that with active drug, there was a complete response in 25% of participants versus only 14% with the placebo. And although a third of participants experienced additional side effects with the active drug-- so remember, this was a crossover trial, so they saw both arms-- 80% preferred cannabis to the placebo medication. So that's clinical trials of cannabis and cancer. But if we expand the base of the pyramid of acceptable evidence to include high-quality clinical trials for health conditions other than cancer and extrapolate back, then I agree fully with Dr. Bowles that there's a growing body of evidence that cannabis may be beneficial in pain management. And there have been many clinical trials done in this arena, and they span myriad pain syndromes, including diabetic neuropathy, post-surgical pain, MS pain, sickle cell pain. And so it does seem like cannabis works for pain management in several other illness models, so we could extrapolate back and hope that it works in cancer pain. And then there is a small body of evidence with nabiximols, which is a pharmaceutical that has a 1 to 1 THC to CBD ratio. And it's a sublingual metered dose spray. And it has been trialed for opioid-resistant cancer pain. And this is not as a single agent, but as an adjuvant to opioids. In early trials, two times as many participants in the active arm as compared to the placebo arm demonstrated a 30% pain reduction. And for the pain specialists who are listening, they will know that is a substantial pain reduction. But then, additional studies fail to meet primary endpoints. I think there were three clinical trials that followed. Nabiximols was found to be safe and effective by some secondary measures, but the FDA opted not to approve nabiximols for cancer pain. So I think there's some suggestion of effect, but there's some smoke, but no fire-- no pun intended. DANIEL BOWLES: I think many of the studies that have been done looking at cannabis-- or cannabinoids-- have been compared to placebo or they've been crossover. And I would say fairly consistently, there is some improvement in pain scores with the cannabis products versus placebo kind of across a wide variety of disease spectrums with regards to pain. I think one of the other questions that a lot of people have asked is, can you decrease people's opiate usage using cannabis? As we know, there's a huge epidemic of opiate misuse in the United States of America right now. And I think many people are looking for ways to decrease opiate usage. There was a nice study done from Minnesota in conjunction with the Minnesota dispensaries-- or state marijuana program-- where some researchers randomized people to starting kind of herbal cannabis products early in their study or three months into their study. So it was kind of a built-in control. And they looked at opiate usage rates, pain scores, quality of life scores, et cetera. What they found is there, again, was some improvement in pain control overall in the cannabis users. However, it did not equate to a decrease in opiate usage. So I think that it's an open question that I think a lot of people want to know the answers to before they start recommending or incorporating cannabis or cannabinoids more widely into their practice. KENT HUTCHISON: It's certainly a complicated issue, in some ways, right? Because the research which is summarized very nicely by both Dr. Braun and Dr. Bowles, it is suggested, but not overwhelming, by any stretch, right? It's not clear-cut. And I think that one of the big issues here we talked about the very beginning is how complicated this cannabis thing is. and Dr. Braun alluded to this also, that there are obviously many different formulations, many potentially active constituents in cannabis. And so what has mostly been studied so far is either synthetic versions of THC or nabiximols, which is probably the closest thing to what some people are using. So I think the jury's still out, for sure. And I think hopefully at some point, what will happen is that some of the products that are actually being used by people-- because most people aren't using nabiximols, most people are not using THC only, hopefully there'll be some trials of the things that people are actually using out there in the real world that will tell us something more about whether it's effective or not. And maybe even more specifically, which constituents-- which parts, together are most effective with respect to pain. DANIEL BOWLES: I think one of the other topics that some of my colleagues have alluded to already is not just cannabis' role in symptom management. I think pain is often what people think of, and people are using it for chemo-induced nausea and vomiting, anxiety, sleep, appetite, but a fair number of patients are also using cannabis or cannabinoids with the hopes that it is going to treat their cancer like a chemotherapy or an immunotherapy may. And oftentimes, patients will point to preclinical studies looking at oftentimes very high doses of THC or CBD that might show tumor cell death or tumor reduction in test tubes. And I spent a fair amount of time-- and I know some of my colleagues spent a fair amount of time-- talking with patients about how it's a big step between cannabis or cannabinoids working to slow cancer growth in a test tube, to working in an animal system, to working in people. ASHLEY GLODE: So what are the most important considerations clinicians should keep in mind before recommending medical cannabis to patients with cancer? DANIEL BOWLES: We should be asking why they want to use cannabinoids. I think just like we might any other medication that people are thinking about trying-- or herbal product that people are thinking about trying-- I think we need to ask why they're interested in using these products. So is it for symptom management? Is it for some of the ancillary side effects of cannabinoids or cannabis? Why are they wanting to use it? And I think trying to incorporate that more than into the medical model, I ask my patients, hey, if you're using this particular product, do you feel like it's doing what you intended it for it to do? If it is and it's legal in your state, great. Do it as you feel fit. If it's not meeting your goals, if it's not helping with the pain, or if it's not helping with the anxiety, or it's not helping with the nausea and vomiting, maybe we should rethink whether we would use it. Just as if I was prescribing more conventional anti-nausea medication and you didn't think it was working, we wouldn't keep using it. So I think that's a really important thing to keep in mind. I think the other thing to know from a safety standpoint is, who else is in the household? We have a psychiatrist on the call with us today. I think there is an ample amount of data that cannabis is not safe for young people. It's not safe for growing brains. And I think we need to make sure, just as we would want people's opiates to be secured, that their cannabinoids and cannabis products are secured as well, from those who do not want to use them. ILANA BRAUN: And the thing I would keep in mind is that in most states, giving patients a medicinal cannabis card is allowing them to access any number of products with different ratios of active ingredients, delivery mechanisms, onset of action, potencies. And if you don't discuss all of these issues with your patients, these are things that they will decide at the dispensary counter, or by discussing with friends and family, or by trial and error. And I think it's really important that we clinicians guide this narrative. ASHLEY GLODE: So what kinds of patients are not good candidates for medical cannabis? DANIEL BOWLES: I would not recommend medical cannabis for people who can't meet some of the criteria we already discussed. So people who can't keep it safe in their households or have concerns about diversion in their own households. Those are people who I think would not be great candidates for medicinal cannabis or cannabinoids. ILANA BRAUN: As the psychiatrist on the call, I would add that I worry for people with a strong history of psychosis, or currently psychotic, or with a strong family history of psychosis. And perhaps those severely immunocompromised, since there is evidence of fungal and mold contamination in some cannabis products. DANIEL BOWLES: The other group of people I discussed this with are patients on immunotherapies. One of the ways that cannabis may be effective in some of the symptoms we discussed is it's an anti-inflammatory agent. One of the ways it could be detrimental for patients on immunotherapies is that it's an anti-inflammatory agent. There is one small study that suggested that patients might have worse responses to immunotherapy who are cannabis users versus those who are not. So that is a conversation I like to have, just so patients feel like they can be informed. I think lastly, cannabis even for people with medical cards, is not free. So there can be a financial burden for people who are using it. So that's something that I'll often bring up with people as well. KENT HUTCHISON: One thing I would add to this would be history of a substance use disorder might also be a consideration here as well. Mainly because you don't know what the person is going to get, and it could be something that lends itself to relapse or encourages a problem. So I would add that to list. ILANA BRAUN: And I would second what Dr. Bowles said about the financial challenges of using cannabis regularly medicinally. It's not something that's covered by insurance, either. So these are out-of-pocket expenses, and they can add up fast, particularly for patients in the oncology space using it for antineoplastic therapy. ASHLEY GLODE: So is there a concern about drug-drug interactions for patients currently undergoing active cancer treatment? DANIEL BOWLES: There are some data that there can be drug-drug interactions with cannabis and certain agents. In particular, cannabidiol, or CBD, is a CYP3A4 inhibitor. And there are a lot of drugs that are metabolized through that particular system. So I think that that's the clinical relevance of those interactions, I think, is sometimes unknown. But that is another topic that I do think we need to make sure we bring up with our patients. ASHLEY GLODE: Thank you. Yeah. So a lot of what we'll do is from a drug interaction perspective, use the FDA-approved products that we have available to run through a drug interaction checker, like Dr. Bowles mentioned. So we'll use dronabinol as the THC-based product and epidiolex as the CBD-based product. There's also some resources, such as natural Medicines Database. And some of the pharmacy programs that we use, you can actually put in marijuana or cannabis as a drug and run drug interaction checks. So there's multiple potential interactions, like he mentioned, through the immune system. But through the cytochrome P450 pathway, cannabis has been shown in some instances to be an inhibitor, sometimes an inducer of certain enzymes, as well as a substrate. So it's really important to work with your pharmacy colleagues to run through different potential interactions that may be present. ILANA BRAUN: I'll just add one thing, just in case that's helpful. I mentioned earlier in the episode that I had a patient who used cannabis as an antineoplastic drug, and targeted very high doses and developed a terrible nausea and vomiting. And when she stopped, so did the nausea and vomiting, even though her chemotherapeutic continued. And I, to this day, don't know if that was a cyclic nausea and vomiting syndrome, which has been known to plague some heavy cannabis users, or whether drug-drug interactions led to her high-dose cannabis triggering high blood concentrations of her cancer-directed therapy at the time. And so I think that drug-drug interactions do need to be carefully weighed. ASHLEY GLODE: So wrapping up, has the medical community stance on medical marijuana shifted in recent years with legalization in many states? ILANA BRAUN: I don't think we know the answer to this, about how sentiment has shifted because there aren't longitudinal studies that I know of examining this question. But we need some. And one could imagine that as medicinal cannabis becomes are commonplace, providers are increasingly confronted with questions about how to guide care and the desire for high-quality clinical trials and in-depth cannabis therapeutics trainings increases-- and as one piece of evidence for this, at the end of 2020 the National Cancer Institute held a first-in-kind four-day conference at the intersection of cannabis and cancer. And so I'm hopeful that grant opportunities will follow from that. DANIEL BOWLES: I think overall there has been more willingness to discuss cannabis in the context of patient care in the last decade. A couple of ways that I see this is I much more frequently see cannabis use described not necessarily in the drug history, or in the social history, but in the medical history, or in their medications, if they're using it for medical or therapeutic purposes. I think the other place that I've noticed cannabis usage become a bit more mainstream is in the clinical trial setting-- not in clinical trials of cannabis, but one of the things that many of us do is clinical trials of new drugs. And very frequently, 10 years ago we ran into trouble trying to get our patients who were using cannabis products for cancer symptom control onto these clinical trials because of potential drug-drug interactions, or just the fear of the unknown. And I feel like we run into that less commonly now. KENT HUTCHISON: I think it's also worth pointing out that there have been more and more podcasts like this one, right? So to the credit of this organization, I think we are seeing some change. I just wanted to highlight that. And I compliment everyone here for putting us together and putting it out there. ASHLEY GLODE: All right. Well, thank you. That is all we have for today. And thank you very much Drs. Braun, Bowles, and Hutchison for a delightful conversation. Thank you so much to all the listeners tuning into this episode of the ASCO Education Podcast. [MUSIC PLAYING] SPEAKER: Thank you for listening to this week's episode to make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit elearning.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.
Welcome to Nature Sound Retreat… You are currently listening to Nature Sounds 432hz: Amazingly Beautiful Music Playing In Light Show Have you ever just wanted to lay on the beach and take in the sounds of the tropics? The sound of a tropical beach ambience mixed with the sound of waves washing ashore is the perfect stress relief after a long day at work or school. Whether you need help to ease insomnia to calming anxiety, Relaxing Waves is the sounds of nature you should decompress to. Nature Sound Retreat releases another entry into your lives with the calming sounds of a tropical beach. Nature Sound Retreat's music stimulates the brain into a specific state using pulsing sound to encourage your brain waves to align to the frequency of the beat. It's supposed to help induce enhanced focus, entranced state, relaxation, and sleep. Proponents of our music have this potential benefits: reduced stress and anxiety increased focus, concentration, and motivation improved confidence better long term memory after exposure to beta pattern frequencies, according to a 2019 study deeper meditation enhanced psychomotor performance and mood Today on YouTube we can see many Meditations tuned to ocean waves inspired track, this specific tuning imbed in it, Healing properties to the Mind and Body. The most elemental state of vibration is that of sound. Every organ and every cell in our precious body absorbs and emits sound with a particular frequency. When two frequencies that resonate at the same Vibration meet, the law of resonance comes into action when that happens one source of frequency is moving energy to the second source of frequency - just like in a forest when one tree moves water to another tree. When we let our body absorb the Healing Music in, we retune ourselves and we absorb new and fresh energy, from the source of the frequency, which is the unified field, the cosmos. Music creates resonance in our physical, mental, emotional and spiritual body. Tune into Relaxation! Nature Sound Retreat was created to bring the best meditation music and nature sounds to inspire, uplift and spread healing energy to the world. Our music utilizes the ancient healing frequencies – the miracle tones that heal. Featuring 432Hz and 963Hz frequencies, binaural beats, ASMR Nature Sounds, Alpha Waves and Delta Waves for Deep Sleep, Stress Relief, Yoga, Study Music for focus and concentration, Massage Music and more. Let our meditation music and nature sounds be your guide to recharging, relaxing and rejuvenating your mind, body, and soul. Use our calming Sleep Music Playlists for quality deep sleep…they are an ideal way to combat and beat insomnia. We combine meditation music with beautiful imagery, stunning landscapes and hypnotic Kaleidoscope videos that will take you on a journey of deep relaxation whilst watching them. Join this channel to get access to perks: https://www.youtube.com/channel/UCcsplj60aQC7mb1rgdhk5sw/join SUBSCRIBE NOW to become part of our community of FREE MEDITATION MUSIC. ►https://naturesoundretreat.com/Youtub... iTunes here: ►https://naturesoundretreat.com/AppleM... ------------------------------------------------------------------------ SPOTIFY here: ►https://naturesoundretreat.com/Spotify ------------------------------------------------------------------------ AMAZON here: ►https://naturesoundretreat.com/Amazon... ------------------------------------------------------------------------ Website: ►https://NatureSoundRetreat.com ------------------------------------------------------------------------ Facebook: ►https://www.facebook.com/NatureSoundR... ------------------------------------------------------------------------ Pinterest: ►https://www.pinterest.com/nature_soun... ------------------------------------------------------------------------ Instagram: ►@NatureSoundRetreat ------------------------------------------------------------------------ Twitter: ►@retreat_sound ------------------------------------------------------------------------ ©2020 Nature Sound Retreat. All Rights Reserved. All videos and music are the sole copyright of Nature Sound Retreat. Licensing inquiries can be sent via Private Message #naturesounds #432hz #NatureSoundRetreat
An interview with Dr. Nancy Baxter from the University of Melbourne in Melbourne, Australia, and Dr. Jeffrey Meyerhardt from Dana-Farber Cancer Institute in Boston, MA, co-chairs on “Adjuvant Therapy for Stage II Colon Cancer: ASCO Guideline Update.” This guideline updates recommendations for adjuvant therapy for patients with resected stage II colon cancer. Read the full guideline at www.asco.org/gastrointestinal-cancer-guidelines. TRANSCRIPT [MUSIC PLAYING] ANNOUNCER: 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. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today, I'm interviewing Dr. Nancy Baxter from the University of Melbourne in Melbourne, Australia, and Dr. Jeffrey Meyerhardt from the Dana-Farber Cancer Institute in Boston, Massachusetts, co-chairs on adjuvant therapy for stage II colon cancer ASCO guideline update. Thank you for being here, Dr. Baxter and Dr. Meyerhardt. NANCY BAXTER: Thank you for having us. JEFFREY MEYERHARDT: Thanks. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines in ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Baxter, do you have any relevant disclosures that are directly related to this guideline topic? NANCY BAXTER: I don't, Brittany. BRITTANY HARVEY: Thank you. And Dr. Meyerhardt, do you have any relevant disclosures that are directly related to this guideline topic? JEFFREY MEYERHARDT: I don't, either. Thank you. BRITTANY HARVEY: Thank you, both. And getting into the content of this guideline, what prompted this guideline update, and what is the scope of this guideline? NANCY BAXTER: Well, it's been since 2004 that we've had a guideline that gives us advice about stage II colon cancer and the use of adjuvant therapy in this group of patients. And it's one where clinicians often have a lot of challenges in helping patients make decisions about what's best for them in terms of long-term survival from colon cancer. There have been changes in guidelines for stage III colon cancer. And so we thought it was timely to reevaluate our best practice recommendations for stage II colon cancer patients. JEFFREY MEYERHARDT: Yeah, I agree, Dr. Baxter. I think that this is one of the most challenging conversations that oncologists have with patients. Should they get chemotherapy? What type of chemotherapy? And as you know, there are a variety of higher risk features, of which we're able to sort of tease out a little better relatively, in terms of thinking about someone's stage II disease and trying to bring all that data together and provide some framework in the conversation for clinicians to have with patients. BRITTANY HARVEY: Great, thank you both for that background information. So then this guideline covers four clinical questions. And I'd like to review the recommendations for each question. So Dr. Baxter, starting with question 1, what does the guideline recommend for patients with resected stage II colon cancer regarding the benefit of fluoropyrimidine-based adjuvant chemotherapy versus surgery alone? NANCY BAXTER: So overall, what we did was we looked at the risk that individual patients with stage II colon cancer have. So for patients that are at low risk of recurrence-- and so those are patients with stage IIA or T3 tumors that have at least 12 sample lymph nodes in the surgical specimen and don't have any high-risk features, and I'll go over those with the later recommendations-- these patients do not need adjuvant chemotherapy. It should not be routinely offered to them because the harms may outweigh the benefits. And so the evidence of that, although the quality of the evidence was relatively low, there is quite a bit of evidence that, really, the benefits do not outweigh the risks in this particular group. That is different for patients that are at higher risk, though, within the stage II group. And so those are the patients with stage IIB or stage IIC colon cancer. So those are T4 lesions that either penetrate through the visceral peritoneum or invade surrounding organs. And in those patients, adjuvant chemotherapy may have more benefit. And so a discussion of the potential benefits and risks of harms associated with chemotherapy should be had with patients. And those are patients that should be offered adjuvant chemotherapy for their disease. Now, there's a group of patients with high-risk features-- so not the stage IIB or stage IIC-- but there's a group of patients within stage IIA. So these are patients that are T3 patients where there are high-risk features. And chemotherapy may be offered to these patients, based on their risk features. So I'll go over a little bit about what the high-risk features are that might make patients included in this group. So that is sampling of fewer than 12 lymph nodes in the surgical specimen, perineural or lymphatic invasion, poor or undifferentiated tumor grade, intestinal obstruction, tumor perforation, and grade BD3 tumor budding. That's more than, or equal to, 10 buds in the tumor. And so that's because these patients are at higher risk of recurrence, and the chemotherapy may be more beneficial in these patients because they have a higher baseline risk of recurrence. There were a few risk factors that it was really challenging to make any decision on. And that was specifically circulating DNA. We know that that's an area of great interest, but there really was not enough evidence of the predictive value of ctDNA when you're looking at adjuvant chemotherapy in this group to make a recommendation. We'd expect future versions of this guideline to have some recommendations about that. We do know that there is controversy around the timing of chemotherapy. So we didn't include reports on this for the guideline because we didn't have enough related to stage II colon cancer and the role of adjuvant therapy. But the trials have generally started patients on chemotherapy within six to seven weeks of surgery. And finally, all of this needs to be a part of shared decision-making. So particularly for patients at higher risk-- so stage 2A at higher risk-- it's important that this is discussed-- the risks and benefits of chemotherapy, and the possible benefits with respect to the risk of recurrence for these patients-- is discussed as part of the shared decision-making process to come to an ultimate decision about the use of chemotherapy. BRITTANY HARVEY: Understood. Thanks for detailing those recommendations stratified by risk and identifying what those high-risk features are. So then, additionally, Dr. Meyerhardt, is there a benefit of fluoropyrimidine-based adjuvant chemotherapy for patients with tumors that exhibit mismatch repair deficiency or microsatellite instability or patients with proficient mismatch repair, or microsatellite-stable, tumors? JEFFREY MEYERHARDT: Yeah, so this was a specific question that we also looked at. What we know is about 15% of stage II colon cancers have evidence of mismatch repair or microsatellite insufficiency. And data that was realized now several decades ago on several different papers-- one larger one published in The New England Journal by Dan Sargent-- showed that patients who have stage II disease who receive a fluoropyrimidine only seem to not benefit if they have microsat instability. And there was actually some evidence that they may actually have harm, or have a worse outcome. So it is not a routine recommendation to use a fluoropyrimidine-only treatment regimen in patients who have MSI-high or deficiency of mismatch repair in stage II disease. However, there are some qualifying statements that we reviewed and were important to think about in patients. So what we know is, again, some of those patients will have some high-risk features and particularly T4 tumors or some other high-risk features, except for poor differentiation, that the use of oxaliplatin may actually be a consideration in those patients. And that's basically from indirect evidence of a disease-free survival benefit with the addition of oxaliplatin in the population of patients with stage II disease that were included in the MOSAIC trial, one of the original trials that looked at the addition of oxaliplatin to a fluoropyrimidine as adjuvant therapy for colon cancer. We specifically carved out poor differentiate is not considered a high-risk prognostic feature in those patients. And so poorly differentiated tumors alone should not be a part of the decision in offering adjuvant therapy with a fluoropyrimidine or fluoropyrimidine-oxaliplatin for MSI-high or deficient mismatch repair protein tumors. And the other patients who have either proficient mismatch repair proteins or microsatellite instability are actually including the other parts of the guideline, so what Dr. Baxter just talked about and some of the other questions that we tackled that you'll be going to next. BRITTANY HARVEY: Great. Thank you for covering those recommendations for that particular patient population. So then, Dr. Baxter, if adjuvant therapy is recommended, is there a benefit to adding oxaliplatin to fluoropyrimidine-based chemotherapy? NANCY BAXTER: Well, this is obviously a question that oncologists will face when they're deciding to give adjuvant chemotherapy to high-risk stage II colon cancers or people with T4 stage IIB or C colon cancers. And you know, here's where it's challenging to make recommendations. Because we don't have a lot of evidence for this specific group. And this is why clinicians have such a challenge making recommendations for these patients. Because actually, there's insufficient evidence to routinely recommend the addition of oxaliplatin, meaning that we have to base our decisions on the best evidence that we have. And the best evidence we have, as we've talked about, is the MOSAIC trial. And so in the MOSAIC trial, a time to recurrence was longer with oxaliplatin-based adjuvant chemotherapy. And so it may be for some patients that the addition of oxaliplatin makes sense in terms of improving their overall outcome. And again, it needs to be a shared decision-making approach with the discussion of the potential benefits and risks of harms of the addition of oxaliplatin to fluoropyrimidine-based chemotherapy, so again, discussions between the oncologist and the patient. But that is with the exception of patients who are MSI-high. So those patients need oxaliplatin. If they're going to get chemotherapy, they shouldn't have 5FU-based chemotherapy alone, as we've just discussed. BRITTANY HARVEY: Great. And definitely, that shared decision-making is key. And I appreciate you reviewing the evidence behind these recommendations, as well. So then, the last clinical question addressed in this guideline, Dr. Meyerhardt, if adjuvant oxaliplatin-containing chemotherapy is considered, are outcomes affected by reducing the treatment duration from six months to three months? JEFFREY MEYERHARDT: Sure. So this was the last clinical question that the committee considered. And it is based on the IDEA collaboration. So the IDEA collaboration was the International Duration Evaluation of Adjuvant Chemotherapy. It was six trials that were done internationally-- one in the United States, one in Japan, and four in Europe-- that included patients both with stage II and stage III colon cancer. They receive three versus six months of therapy. Each of the trials had different chemotherapy choices in the sense that the United States trial, FOLFOX was the only choice that could be offered to patients, where in all the other trials, it was a physician and patient choice regarding the use of FOLFOX or capecitabine and oxaliplatin. And that, as people who know the data, is relevant to some of the discussion. And so the goal of the collaboration was to look at if we can give patients three months of therapy and not compromise outcome. And the main reason for that is we know that the peripheral neuropathy that's cumulative with oxaliplatin increases with more months of treatment. So patients who only receive three months of oxaliplatin have less likelihood of more significant cumulative neuropathy and will have less impact on function by receiving less oxaliplatin overall. Four of the trials included patients with stage II disease. And those trials, again, pooled their data and looked at the duration question in terms of for stage II patients. Those patients had high-risk disease, some high-risk feature, as discussed earlier. And what was shown is that for the patients, overall, there was not clear evidence of noninferiority with three versus six months. But when you looked at the patients who received capecitabine and oxaliplatin, the absolute five-year disease-free survival was 81.7% versus 82% for three versus six months of CAPOX, so essentially the same, with a hazard ratio of 1.02, and the confidence interval spanned across 1. And so those really didn't look like there was any compromise in outcome for patients to receive CAPOX for three months versus six months. For those patients who received FOLFOX, three months of chemotherapy led to a five-year disease-free survival of 79.2% versus 86.5% if you received six months of FOLFOX with a hazard ratio 1.41. So again, those data would suggest that if one was to choose FOLFOX, giving six months of therapy for high-risk stage II patients may be preferable to not potentially compromise some benefit in terms of disease-free survival. So again, the overall conclusion was it's a discussion with a patient regarding choice of therapy, whether receiving capecitabine, oxaliplatin or FOLFOX and then, based on that, consideration of the duration where we were most comfortable saying that three months of capecitabine, oxaliplatin is sufficient for high-risk patients when appropriate discussion between the clinician and the patient. BRITTANY HARVEY: Great. Thank you for explaining the nuance of that trial and your recommendation. So finally, to wrap us up, in your view, how does this guideline impact both clinicians and patients? JEFFREY MEYERHARDT: Yeah, so again, the last time ASCO had addressed guidelines for stage II patients was over 15 years ago. And there are more data. It was really early in the days of understanding the incorporation of oxaliplatin. There was no data versus the three versus six months. And there were less analyses trying to look at some of those particular high-risk features. So these are all important considerations in those discussions with stage II patients. And the importance of the guidelines are really to provide that framework on the various things you think about when you have a stage II patient and how to have those shared decision-making discussions with the patient. Again, it's not, probably, appropriate for all patients to receive adjuvant therapy, particularly lower risk. And even for higher risk patients, it is weighing the plus or minuses of the potential toxicities with what we know potentially are benefits. NANCY BAXTER: Yeah, I think that's very true. And I think, as anyone who treats colon cancer, or stage II colon cancer patients, is aware, this is not a homogeneous population. So in terms of the outcomes, there are people that do extremely well with surgery alone and people who, unfortunately, recur even after chemotherapy and surgery. And the future needs to focus on being able to differentiate those patients most likely to benefit from chemotherapy from those that are not likely to benefit. What we found in reviewing the evidence is we've moved forward from 2004, but we still have a long way to go. So I really hope when the next guideline is written that we're much closer to being able to identify those patients who would most benefit from chemotherapy in this group. Because we know there are patients who benefit from chemotherapy in this group. It's just we're still not perfect at identifying those people. So again, these conversations with patients are so important to talk about the limits of our knowledge, which I think is another important thing of this guideline is establishing what the limits of our knowledge are. But I think there are patients that you can confidently not give chemotherapy to. And that's very reassuring, both to clinician and to patients. And then this guideline kind of outlines the limits of our knowledge. And that's also important for clinicians and patients to understand. BRITTANY HARVEY: Definitely. I appreciate you both highlighting the importance of shared decision-making throughout this conversation that we've had. So I want to thank you so much for your work on this important guideline update and for taking the time to speak with me today, Dr. Baxter and Dr. Meyerhardt. NANCY BAXTER: Thank you very much. JEFFREY MEYERHARDT: Thank you. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/gastrointestinal cancer guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, available in iTunes or the Google Play store. If you've enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode. [MUSIC PLAYING]
An interview with Dr. Megan Daly from University of California in Davis, California and Dr. Navneet Singh from the Postgraduate Institute of Medical Education & Research in Chandigarh, India, co-chairs on “Management of Stage III Non–Small-Cell Lung Cancer: ASCO Guideline.” They summarize guideline recommendations on five subtopics – evaluation & staging, surgery, neoadjuvant therapy, adjuvant therapy, and unresectable disease. Read the full guideline at www.asco.org/thoracic-cancer-guidelines. TRANSCRIPT [MUSIC PLAYING] ANNOUNCER: 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. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at ASCO.org/podcasts. My name is Brittany Harvey, and today, I'm interviewing Dr. Megan Daley from University of California in Davis, California, and Dr. Navneet Singh from the Post-Graduate Institute of Medical Education and Research in Chandigarh, India, co-chairs on management of stage III non-small cell lung cancer ASCO guideline. Thank you for being here, Dr. Daley and Dr. Singh. MEGAN DALEY: Thank you for having us. NAVNEET SINGH: Thank you for having us, too. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in the Journal of Clinical Oncology. Dr. Daley, do you have any relevant disclosures that are directly related to this guideline topic? MEGAN DALEY: I have research funding from EMD Serono, Merck, and Genentech. BRITTANY HARVEY: Thank you for those disclosures. Then Dr. Singh, do you have any relevant disclosures that are directly related to this guideline? NAVNEET SINGH: No, I have no financial conflicts of interest. BRITTANY HARVEY: Thank you. Getting into the content of this guideline, Dr. Singh, can you give us an overview of both the scope and the purpose of this guideline? NAVNEET SINGH: Yes, absolutely. So this guideline has been developed to assist clinicians involved in the management of patients with stage III non-small-cell lung cancer, or NSCLC, as we call it briefly. Now, stage III NSCLC represents one of the most heterogeneous subgroups of lung cancer. Consequently, it is also the subgroup in which the choice of multimodality treatment and the sequence of multimodality treatment varies significantly amongst clinicians, with variations being observed across institutes, as well as within an institute. And we sincerely hope that, with the help of this guideline, clinicians can accurately confirm the presence of stage III disease and offer the most appropriate treatment based on clinical and radiographic characteristics, as well as other medical factors that influence treatment decision-making. This evidence-based guidance also seeks to provide clarification on the common clinical dilemmas that clinicians may have while evaluating a patient with suspected or known stage III NSCLC. BRITTANY HARVEY: Thank you for that background information, Dr. Singh. Then, Dr. Daley, this guideline addresses five main sections, evaluation and staging, surgery, neoadjuvant therapy, adjuvant therapy, and unresectable disease. So starting with evaluation and staging, what are the key recommendations for workup for patients with suspected stage III non-small cell lung cancer? MEGAN DALEY: Our first recommendation for such patients is that they should undergo a history and physical exam and a CT scan of the chest and upper abdomen with contrast, unless it's contraindicated. If metastatic disease is not identified on CT, those patients should go on to a PET CT scan and MRI of the brain. If the patients are being considered for curative intent treatment, the guideline recommends pathologic mediastinal lymph node assessment. And we recommend that endoscopic techniques should be offered as the initial staging modality, if available. If not available, invasive surgical mediastinal staging should be offered. And finally, for patients who have suspected or confirmed stage III lung cancer, we recommend that multidisciplinary discussion should occur prior to any initiation of a treatment plan. BRITTANY HARVEY: Great, I appreciate your reviewing those recommendations. So following that, Dr. Singh, what does the guideline recommend regarding which patients with stage III non-small-cell lung cancer should be considered for surgical resection? NAVNEET SINGH: So in this guideline, the recommendation which has come forth is that for patients with stage IIIA, basically N2 disease, induction therapy should be followed by surgery with or without adjuvant therapy if several conditions are met. Basically, a complete resection of the primary tumor and the involved lymph nodes is deemed feasible, and three nodes or contralateral lymph nodes are deemed to be not involved, and the expected perioperative 90-day mortality is low, typically 5% or less. Another recommendation is that for selected patients with the P4N0 disease, surgical resection may be offered if medically and surgically feasible following multidisciplinary review. We would like to emphasize here that surgeons should always be involved in decisions regarding the feasibility of surgical resection. And they are an integral part of a multidisciplinary evaluation for surgical resection for stage III NSCLC patients. BRITTANY HARVEY: Great. Then Dr. Singh just reviewed who should be considered for surgical resection. So Dr. Daley, for patients with potentially resectable stage III non-small-cell lung cancer, what are the key recommendations for neoadjuvant therapy? MEGAN DALEY: Our first recommendation is that patients who are planned for a multimodality approach that will incorporate surgery should receive systemic neoadjuvant therapy. Second, that those patients with N2 disease who are planned for surgical resection should receive either neoadjuvant chemotherapy or neoadjuvant concurrent chemoradiation. And finally, for patients with a resectable superior sulcus tumor, neoadjuvant concurrent chemoradiation should be administered. BRITTANY HARVEY: Understood. Then in addition, Dr. Singh, for patients with resected stage III non-small-cell lung cancer, what are the key recommendations for adjuvant therapy? NAVNEET SINGH: So the panel came up with three recommendations for adjuvant treatment. The first is that patients with resected stage III NSCLC who did not receive neoadjuvant systemic therapy should be offered adjuvant platinum-based chemotherapy. The second recommendation which we came up was that for patients with resected stage III disease and presence of a sensitizing EGFR mutation-- classically, exon 19 deletion or the L858R exon 21 point mutation-- they may be offered adjuvant osimertinib, which is an EGFR inhibitor, after platinum-based chemotherapy. And this is based upon the ADAURA trial, which was published last year. And the third recommendation was that for patients with completely resected NSCLC and mediastinal involvement N2 disease, but without extracapsular extension, post-operative radiotherapy should not be routinely offered. BRITTANY HARVEY: OK. And then the last section of recommendations covers unresectable disease. So Dr. Daley, what does the guideline recommend regarding the management of unresectable stage III non-small-cell lung cancer? MEGAN DALEY: The guideline first recommends that these patients who have a good performance status should be offered concurrent, rather than sequential, chemoradiation, that concurrent chemotherapy delivered with radiation should include a platinum-based doublet, preferably cisplatin-etoposide, carboplatin-paclitaxel, or cisplatin-pemetrexed or cisplatin-vinorelbine. The patients who are not candidates for concurrent chemoradiation, but who are potentially candidates for chemotherapy, should be offered sequential chemoradiation, rather than radiation alone, that patients receiving concurrent chemoradiation should be treated to 60 gray. And that's based on the results of RTOG 0617. We also recommend within the guideline that doses higher than 60 gray and up to 70 gray could be considered for selected patients, with careful attention to doses to the heart, lung, and esophagus, among other organs. The guideline also recommends that patients receiving definitive radiation without chemotherapy, that hypofractionation using slightly larger doses could be considered-- over 2 gray per fraction, and up to 4 gray per fraction, and that patients without disease progression during concurrent chemoradiation should be offered consolidation durvalumab, based on the PACIFIC trial. BRITTANY HARVEY: Thank you both, then, for reviewing the key recommendations of this guideline. So, Dr. Singh, in your view, what is the importance of this guideline, and how does it impact clinicians? NAVNEET SINGH: I think this guideline will go a long way in helping clinicians who are involved in the diagnosis and treatment of lung cancer, especially stage III NSCLC. As mentioned earlier, this is a very heterogeneous disease. And there are several challenging situations, both in the context of diagnosis, as well as treatment. And using this guideline, which has an extensive evidence review, as well as the development of two very helpful algorithms, we sincerely hope that clinicians who are both in academic centers as well as in practice in the community are able to accurately diagnose stage III, appropriately stage it, and offer the best treatment, given the patient characteristics and the disease characteristics and available resources. BRITTANY HARVEY: Great. Those are important points. So then, finally, Dr. Daley, how will these guideline recommendations affect patients? MEGAN DALEY: Well, we hope very much that these guidelines will help patients consistently receive high-quality care for their stage III lung cancer. In particular, we're hoping that the recommendation from multidisciplinary assessment of patients prior to treatment is carefully followed. We're hoping that some of the recommendations surrounding the appropriate workup for patients may help ensure that all patients receive a thorough and complete workup prior to initiation of treatment. And the guideline, in particular, is highlighting some of the more recent developments in stage III lung cancer, such as the use of consolidation durvalumab based on the PACIFIC trial, the use of osimertinib in resectable disease based on the ADAURA trial. And we're hoping to make sure that these results are disseminated to practitioners everywhere so that patients can receive the latest and best care for their stage III lung cancer. BRITTANY HARVEY: Understood. Yeah, as you both mentioned, we hope that this has a positive impact for both clinicians and patients. So I want to thank you both for all of your hard work to develop this guideline and the evidence-based recommendations along with it. And thank you for taking the time to speak with me today, Dr. Daley and Dr. Singh. MEGAN DALEY: Thank you so much for having us. NAVNEET SINGH: Thank you. BRITTANY HARVEY: And thank you to all of our listeners for tuning into the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/thoracic-cancer-guidelines. You can also find many of our guidelines and interactive resources in the free ASCO guidelines app, available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode. [MUSIC PLAYING]
An interview with Dr. David Schiff from the University of Virginia Medical Center in Charlottesville, VA, and Dr. Michael Vogelbaum from Moffitt Cancer Center in Tampa, FL, co-chairs on “Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline.” This guideline comprehensively addresses the treatment of brain metastases from non-hematologic solid tumors, including surgery, systemic therapy, radiation therapy, and timing of therapy. Read the full guideline at www.asco.org/neurooncology-guidelines. TRANSCRIPT [MUSIC PLAYING] SPEAKER 1: 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. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today I am interviewing Dr. Michael Vogelbaum from Moffitt Cancer Center in Tampa, Florida, and Dr. David Schiff from the University of Virginia Medical Center in Charlottesville, Virginia, Co-chairs on Treatment for Brain Metastases, American Society of Clinical Oncology, Society for Neuro-Oncology, and American Society for Radiation Oncology Guideline. Thank you for being here, Dr. Vogelbaum and Dr. Schiff. MICHAEL VOGELBAUM: My pleasure. BRITTANY HARVEY: Before we begin, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guideline in The Journal of Clinical Oncology Dr. Vogelbaum, do you have any relevant disclosures that are directly related to this guideline topic? MICHAEL VOGELBAUM: I have no disclosures relevant to this guideline. BRITTANY HARVEY: Thank you. Then, Dr. Schiff, do you have any relevant disclosures that are directly related to this guideline topic. DAVID SCHIFF: Hi, Brittany. No, I do not. BRITTANY HARVEY: Great. Then first, Dr. Schiff, can you give us an overview of the scope and the purpose of this guideline? DAVID SCHIFF: Sure. Our overall purpose was to provide guidance on the appropriate treatment of adult patients with parenchymal brain metastases from solid tumors, encompassing surgery, radiation, and systemic therapy, as well. Previous guidelines in this area were for the most part produced by neurosurgeons and radiation oncologists for their respective professional organizations, although they did incorporate multidisciplinary input. But over the last decade, treatment options for certain types of brain metastases have undergone a substantial change. The expanding armamentarium for medical oncologists in treating both extra-CNS disease as well as brain metastases highlighted the need for a new set of guidelines to evaluate the role of systemic approaches, such as targeted agents and immunotherapy, for the primary treatment of brain metastases in the context of more established treatments like surgical resection, radiosurgery, and fractionated radiotherapy. Additionally, recent studies have clarified the role of radiation techniques like whole brain radiation with hippocampal avoidance and radiosurgery to surgical resection cavities. By assembling a multidisciplinary group of experts from surgical neuro-oncologists, medical oncologists, neuro-oncologists, and radiation oncologists, we sought to provide as comprehensive and up to date a set of therapeutic guidelines as possible. In order to accomplish this, the panel performed a systematic review of randomized as well as nonrandomized evidence from 2008 through April, 2020. We focused on the roles of surgery, systemic therapy, and radiation therapy, as well as the timing and interactions among these modalities. And we included all randomized clinical trials, as well as large single arm phase II studies and institutional case series, and we also reviewed case control and cohort studies. BRITTANY HARVEY: OK, great. That's helpful background. And then you mentioned a couple focus areas, as well, of the systematic review. And so I'd like to review the key recommendations that were based off that evidence. So, starting with surgery, Dr. Vogelbaum, what are the key recommendations for surgery in adult patients with brain metastases? MICHAEL VOGELBAUM: So, the role of surgery, I think, was well established via randomized trials to some degree, and then via some of the larger single arm studies. Patients with suspected brain metastases without a primary cancer diagnosis were felt to benefit from surgery to obtain a diagnosis and undergo removal of the tumor. But more to the point, patients with larger tumors with mass effect-related symptoms are the ones most likely to benefit from surgery. What we also noted was that patients who have multiple brain metastases with extensive and uncontrolled systemic disease are unlikely to benefit from surgery unless the remaining disease is controlled via other measures, typically medical measures. We also contemplated the type of resection performed, the technique being used. There was some developing literature looking at the techniques of either an en bloc resection or a piecemeal resection. And when we critically evaluated the literature, we felt that no recommendation could be made regarding the method of resection, as there was not sufficient evidence to support one approach over another. Another technique that is being used more recently is the use of laser interstitial thermal therapy, which is a minimally invasive technique to treat tumors in general. But again, there was insufficient evidence to really be able to make a recommendation for or against the use of LITT, as it's called. BRITTANY HARVEY: OK, thank you for reviewing both those techniques and those recommendations and highlighting where there wasn't enough evidence to actually make a recommendation. So, then, following that, Dr. Schiff, what does the guideline recommend for patients with brain metastases regarding systemic therapy, including chemotherapy, immunotherapy, and targeted agents? DAVID SCHIFF: Brittany, there is a role for systemic therapy as the initial or primary modality in some cases, but I think it's really important to emphasize this only pertains to patients whose brain metastases are asymptomatic and those with particular histologies or molecular profiles. So, there are really-- there are three primary sites for which targeted or immunotherapy can be considered. The first is non-small cell lung cancer, for which osimertinib, or if you're in China, where there's access to another drug called icotinib, specifically for EGFR-mutated disease, alectinib, brigatinib, and ceritinib are appropriate approaches in ALK-rearranged asymptomatic brain metastases. And finally, pembrolizumab in combination with pemetrexed and a platinum agent in immunotherapy naive patients whose tumors express PD-L1. The second primary tumor is melanoma. And for melanoma patients who have asymptomatic BRAF V600E mutant brain metastases, dabrafenib with trametinib is an appropriate option to consider. For all melanoma patients with asymptomatic brain metastases, ipilimumab with nivolumab is also an option. And finally, for breast cancer, the combination of tucatinib, trastuzumab, and capecitabine for HER2 positive asymptomatic brain metastases in patients who have progressed on previous anti-HER2 antibody therapy. When patients treated with systemic therapy progress intracranially, local therapies such as surgery, radiation, and radiosurgery should not be deferred. BRITTANY HARVEY: OK, those are helpful notes for clinicians, and particularly around the primary tumor sites. So, then, Dr. Vogelbaum, what are the key recommendations for radiation therapy in patients with brain metastases? MICHAEL VOGELBAUM: So, Brittany, the panel started by noting which patients would not benefit from radiation therapy, in particular, those with asymptomatic brain metastases and a poor performance status, with a Karnofsky Performance Score, or KPS, of less than or equal to 50, or performance status of less than 70 and no systemic therapy options. In those cases, radiation therapy is unlikely to be of real benefit. But then when speaking to the different modalities of radiation to be used, a lot of the review focused on the two most commonly used modalities, which is Stereotactic Radiosurgery, or SRS, versus Whole Brain Radiotherapy, or WBRT. And the first recommendation was that SRS alone as opposed to either whole brain radiotherapy alone or a combination of the two should be offered to patients with one to four unresected brain metastases, except for the situation of small cell carcinoma, which has a different approach that's used often with prophylactic cranial irradiation. So, that's a separate group. But for others, SRS is the modality that should be offered. And then for patients who underwent surgical resection of their brain metastases, we know that there needs to be some form of radiation treatment to the surgical cavity. And the recommendation was that SRS alone should be offered to those patients if the surgical cavity can be safely treated, and considering the extent of remaining intracranial disease. Obviously, for patients who have a lot of disease but otherwise have a treatable systemic disease, then whole brain radiotherapy may make more sense. But for the ones that are more limited after surgery, it should be SRS. And then when the panel considered a situation where you have patients with more than four unresected metastases and the options included radiosurgery, whole brain radiotherapy, or radiosurgery plus whole brain radiotherapy-- and in general, these are reasonable options. But it was felt that SRS may be preferred for patients with better prognosis or where systemic therapy that is known to be active in the central nervous system is available. Additional recommendations revolved around both protective, radioprotective, and radiosensitizing agents. So, in terms of trying to protect memory, there are two approaches that are used. One is to give memantine during whole brain radiotherapy, or to do whole brain radiotherapy using a hippocampal avoidance technique. And it was felt that either one of those or both should be offered to patients who will receive whole brain radiotherapy and have no tumors in the hippocampus, and they're expected to live more than four months. And then finally, that radiation sensitizing agents should not be offered to patients, because they've not been shown to be effective. BRITTANY HARVEY: Understood. And it's helpful to know both what those recommendations are for specific approaches, and as you said, critical to know who will and who will not benefit from radiation therapy. So, then we've just reviewed the key surgery, systemic therapy, and radiation therapy recommendations. Dr. Schiff, did the panel recommend anything regarding the timing of surgery, radiation therapy, and systemic therapy? MICHAEL VOGELBAUM: The panel had just a couple of points in this regard. Although there are some recent data suggesting a decreased incidence of leptomeningeal metastases in patients who undergo radiosurgery before craniotomy, as compared to the reverse sequence, the panel concluded no recommendation on this point regarding the specific sequence of therapy could be made. And to reiterate, for those circumstances in which systemic therapy may be of use for brain metastases, that therapy should proceed, local therapy like surgery or radiation, only if the brain metastases are asymptomatic. BRITTANY HARVEY: Great. Thank you both for reviewing these recommendations. In your view, Dr. Vogelbaum, what is the importance of this guideline, and how will it impact clinicians? MICHAEL VOGELBAUM: I think one of the important points that David raised that at the beginning was that this really is the most comprehensive look at the evidence revolving around the treatment of patients with brain metastases and leptomeningeal disease. And in particular, this may be new information for an audience that has not been involved in that treatment for many decades, the medical oncology community. So, I think some of the impact on clinicians may be that the guidelines will help them understand the durability of surgery and radiosurgery, and those had been the only treatments available for a long time. And so now we have these new medical therapies that are showing activity in the brain, but one needs to balance that against what is known about the effective treatments in the past. Some of the new targeted immunotherapies may not provide as consistent or durable of a benefit as has been shown previously with surgery and radiotherapy. Hopefully, understanding this challenge with respect to consistency and durability will serve to support the development of phase 0 or window of opportunity clinical trials to better understand the determinants the biological determinants of response or resistance to systemic therapies we want to improve on that, for sure, and those clinical trials are going to be essential for us to be able to do that. And then ultimately, also, identify opportunities to synergistically combine radiation and medical therapies and better understand the timing of these combinations. This is a great area for clinical trial development in the future. BRITTANY HARVEY: Definitely. We'll look forward to future research in those areas. So then, finally, Dr. Schiff, to wrap us up, how will these guideline recommendations affect patients? DAVID SCHIFF: Yeah. Over the last 30 years, the management of brain metastases have involved hugely, from an area where almost everyone got whole brain radiation therapy and many patients died from their brain disease. The use of local therapies like surgical resection and radiosurgery has greatly improved local control of brain metastases. And with options like radiosurgery alone for a limited number of brain metastases, systemic therapies as the initial approach, and hippocampal avoidant whole brain radiation therapy with memantine, patients are experiencing improved long term cognitive function and quality of life, as well. So, I think the careful delineation of the role of each of these modalities that these guidelines provide will really help maximize benefit and minimize the risk for this very large number of cancer patients. BRITTANY HARVEY: Definitely, improve quality of life is always a goal. So, I want to thank you both for your work on these guidelines and thank you for taking the time to speak with me today, Dr. Vogelbaum and Dr. Schiff. DAVID SCHIFF: My pleasure. MICHAEL VOGELBAUM: Thank you, Brittany. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. To read the full guideline, go to www.asco.org/neurooncology guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in iTunes or the Google Play Store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe, so you never miss an episode. [MUSIC PLAYING]
An interview with Dr. Jaishri Blakeley from Johns Hopkins University School of Medicine in Baltimore, MD, and Dr. Nimish Mohile from the University of Rochester Medical Center in Rochester, NY, co-chairs on “Therapy for Diffuse Astrocytic and Oligodendroglial Tumors in Adults: ASCO-SNO Guideline”. This guideline addresses evidence-based therapies for patients with newly diagnosed and recurrent gliomas. Read the full guideline at www.asco.org/neurooncology-guidelines. TRANSCRIPT [MUSIC PLAYING] SPEAKER 1: 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. SPEAKER 2: Hello, and welcome to the ASCO Guidelines Podcast Series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today, I'm interviewing Dr. Jaishri Blakeley from Johns Hopkins University School of Medicine in Baltimore, Maryland, and Dr. Nimish Mohile from the University of Rochester Medical Center in Rochester, New York, co-chairs on therapy for diffuse astrocytic and oligodendroglial tumors in adults American Society of Clinical Oncology and Society for Neuro-Oncology guideline. Thank you for being here, Dr. Blakeley and Dr. Mohile. SPEAKER 3: Thank you. SPEAKER 4: Thank you. SPEAKER 2: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with a publication of the guideline in the Journal of Clinical Oncology. Dr. Blakeley, do you have any relevant disclosures that are directly related to this guideline topic? SPEAKER 3: No, I do not. SPEAKER 2: Thank you. And Dr. Mohile, do you have any relevant disclosures that are related to this guideline topic? SPEAKER 4: No, I don't have any relevant disclosures. SPEAKER 2: Great. Thank you. Then let's get into the content of this guideline. So Dr. Mohile, can you start by giving us a general overview of the scope and purpose of this guideline? SPEAKER 4: Yeah, so over the past 10 years, there have been several positive clinical trials in various glioma subtypes, and several of them have demonstrated a benefit for chemotherapy. The primary purpose of this guideline is to help practicing clinicians understand how these trials might impact treatment for patients with gliomas. During this period, there's also been two updates to the World Health Organization classification of gliomas, and the terminology of gliomas has changed. So what we call tumors today is different from what we might have called them 10 years ago. And so a second purpose of our guideline is essentially to provide a key or a translator so a clinician can look at a pathology report today in 2021 with a current terminology and know what to do with that patient and what treatment best fits for that patient today based on what they would have been called in a trial several years ago. SPEAKER 2: Great. That makes a lot of sense. So then Dr. Blakeley, looking at this guideline, it addresses four clinical questions, which are after maximal safe surgical resection, what are the evidence-based therapies for adults with newly diagnosed glioma including optimal regimens, settings, and timing of therapy? Then also, what are the appropriate therapies for adults with recurrent glioma, including optimal regimens, settings, and timing of therapy, followed by what should the effect of MGMT promoter methylation status be on choice of therapy and if there are subpopulations that should affect the choice of therapy. I'd like to review the key recommendations for those clinical questions. In reading through the guideline, the expert panel provided recommendations based on the IDH mutation status and the diagnostic categories in the WHO 2016 and 2021 classification systems for tumors of the central nervous system. So it seems appropriate to review the recommendations in this manner as well. Starting with IDH mutant astrocytic and oligodendroglial tumors, what is recommended for patients with oligodendroglioma, IDH mutant, 1p19q deleted CNS WHO grade 2 or 3? SPEAKER 3: Absolutely, and I'll just summarize for our listeners to help simplify that as you said, essentially, all of the guidelines are divided along molecular markers. And the first cohort are 1p19q co-deleted gliomas. Something that is a 1p19q deleted gliomas also an oligodendroglioma. Those are interchangeable. If you are 1p19q co-deleted, you have oligodendroglioma and vise versa. In general, 1p19q co-deleted tumors also are IDH mutant. So you can consider that one bundle. And oligodendroglioma is something that is 1p19q co-deleted and IDH mutant. And for that whole classification, whether it's WHO grade 2 or WHO grade 3, the recommendation is for radiation followed by the combination of procarbazine, CCNU, and vincristine, based on two prospective studies that showed similar results at different time points. There are a couple of modifications to that guideline. There is a statement that if people feel that the combination of Procarbazine, CCNU, and Vincristine, also called PCV, is too toxic, they can consider temozolomide as an alternative for this subclass of tumors 1p19q co-deleted IDH mutant. And also, importantly, the 1p19q co-deleted grade 2 gliomas are some of the best performing tumors in terms of prognosis of all glial tumors and maybe all CNS tumors. And so there is a statement in the recommendations that say-- it says it is reasonable to defer therapy under appropriate circumstances. And the text goes into what those appropriate circumstances might be, including how much of a resection could be achieved, what the functional status of the person is, how old they are, et cetera. But big picture-- 1p19q co-deleted tumor equals an oligodendroglioma, and those are almost all IDH mutant. And the bottom line recommendation is radiation followed by PCV with the parentheses saying temozolomide might be a reasonable alternative to PCV, and if you have a particularly benign presentation with a grade 2 tumor, you can consider deferring that therapy start for a time. The next big bundle is astrocytic tumors that are not 1p19q co-deleted. So in the guidelines, those are termed as 1p19q non-co-deleted. And those tumors do come in two flavors-- IDH mutant or IDH wild type. And I'm going to focus on the IDH mutant because they track closer to the oligodendroglioma, but they are kind of a bridge between the very good prognosis associated with oligodendrogliomas and the more aggressive prognosis associated with malignant gliomas. And for this cohort, the 1p19q non-co-deleted IDH mutant cohort, the recommendation is for radiation therapy with adjuvant chemotherapy, and there is data that supports that adjuvant chemotherapy being either PCV or temozolomide. We don't prioritize between those two regimens. And why I'm highlighting the word adjuvant is in some centers, there is a tendency to use temozolomide concurrent with radiation therapy. And the recommendation for these 1p19q non-co-deleted IDH mutant WHO grade 2 tumors is not to use it concurrent but to use it in the adjuvant setting. And then I will round out with talking about IDH wild type. So now we're, again, 1p19q non-co-deleted but IDH wild type. Those tumors may act closer to the glioblastoma. And in that setting, we would say-- the recommendations say to treat with radiation and consider concurrent temozolomide as you would with glioblastoma or only adjuvant temozolomide as you would with the lower grade astrocytoma. SPEAKER 2: Great. Thank you for going through that and providing such clarity to those recommendations. Then following that, Dr. Mohile, moving on to glioblastoma and other IDH wild type diffuse glioma, what are the key recommendations for people with newly diagnosed glioblastoma IDH wild type CNS WHO grade 4? SPEAKER 4: So in the current classification, IDH wild type CNS World Health Organization grade 4 is what we've known of classically as glioblastoma. And for patients with glioblastoma who are fit and can tolerate therapy, we recommend treatment with radiation, concurrent temozolomide, and a six month course of adjuvant temozolomide. We also recommend that they can receive alternating electric field therapy along with the adjuvant temozolomide. Now the recommendations become a little bit more complicated for patients who might not be as fit-- so patients who might be older, have poor performance status, have other measures of frailty. And the way we wrote this is we said that if a patient who is undergoing a six week course of radiation, if that course of radiation, if the benefits did not outweigh the harm, then you could consider alternate regimens. And these include shorter courses or hypofractionated courses of radiation with or without chemotherapy and also includes courses that are chemotherapy alone. So in people who have tumors that have MGMT promoter methylation, we can consider the option of temozolomide alone. So this would be specifically for patients who either are older, more frail, who we feel are going to have difficulty going through a radiation course. There is some data to support this temozolomide alone approach. SPEAKER 2: Thank you. I appreciate you going through those recommendations very clearly as well. You clearly put a lot of effort into these recommendations. So then, Dr. Blakeley, what is recommended for patients with astrocytomas IDH wild type CNS WHO grade 2 or 3? SPEAKER 3: Yes, thank you. So as Dr. Mohile was just saying, for glioblastoma, you can really think about the recommendations for WHO grade 4 very similarly for IDH wild type independent of grade. And that is a new shift in the management of gliomas in adults. Previously, the histologic grading had a lot of weight on whether or not we would offer radiation and chemotherapy. But with the new prognostic and predictive value known associated with the IDH1 mutation or lack of mutation being IDH wild type, the recommendation is if somebody is IDH wild type CNS WHO grade 2 astrocytoma or grade 2 or grade 3, they would be offered treatment similar to a glioblastoma, which would be concurrent radiation and temozolomide followed by adjuvant temozolomide as long as performance status and all other factors support doing so. SPEAKER 2: Understood. I appreciate you providing that information as well. So were there additional areas where the expert panel found evidence either insufficient or was unable to make a recommendation? SPEAKER 4: Yeah, so there's two tumor types where we didn't have enough data to make a specific therapeutic recommendation. The first, unfortunately, is in recurrent glioblastoma. And there were no randomized controlled trials that demonstrated a benefit of one therapy over another. And so our recommendation is that when available, patients should be referred for a clinical trial. The other area is in a tumor type called diffuse midline glioma. This is a tumor characterized by the h3k27 mutation more commonly seen in children. But we do see this in adults. And here as well, there were no randomized trials that could clearly give us guidance on what the best therapy was even in the newly diagnosed setting. And our recommendation here also was, if available, to be considering a clinical trial. SPEAKER 2: Understood. It's important to recognize where there are areas where we're lacking evidence as well. So then, Dr. Blakeley, in your view, why is this guideline important and how will it change practice? SPEAKER 3: Thank you. Well, as Dr. Mohile said at the start, it is quite challenging to review the literature for gliomas in adults because we've had different nomenclature applied across clinical trials and diagnostic studies over the last 10 to 15 years. And this document and these guidelines really seek to be the clearinghouse to help clinicians match up what they see on the pathology report for their patient to the data that is published on phase III studies that has influenced our current standards of care. So I think the most important way it will change practice is bringing clarity to the data that already exists but has not been accessible to providers trying to help patients make the best decisions for them. It also importantly highlighted how much more work is needed. We desperately need new clinical trials for patients with glioblastoma and patients with astrocytoma IDH wild type 1p19q non-co-deleted WHO grade 2 and 3 and the other areas that Dr. Mohile highlighted. But we're hopeful that this will help provide clarity on both what we do know to help us identify patients who have the best chance of truly meaningful benefit from chemotherapy and where we need to invest more resources. SPEAKER 2: Absolutely. It seems like this will be a helpful resource for how to treat now and a guide as to what areas of research should be investigated in the future. So in addition to that, Dr. Mohile, finally, how do you view that these guideline recommendations will impact patients? SPEAKER 4: Yeah, my hope is that this will help standardize our approach to patients with gliomas. In the United States, patients with gliomas get care in all kinds of different settings. And when they're seeing an oncologist, particularly in the community, this might be a very small percentage of the types of cancers that they might be seeing, and it's hard to keep up with all of these trials and hard to keep up with the changes in classification. So our hope is that this guideline helps that oncologist in providing them the clarity, as Dr. Blakeley said, on how to approach treatment here so that all of our patients are getting the best standard of care based on the best available evidence and that they're being considered in those areas where there is not good evidence or referral for clinical trials so that in 10 years, when we put together the next guideline, that we're able to make some progress on some of these questions. SPEAKER 2: Great. Well, thank you both for all of your work that you did to review the literature and produce these evidence-based recommendations and, as you said, provide a real clear and helpful resource to both clinicians and to improve the quality of care for patients. And thank you for taking the time to speak with me today, Dr. Mohile and Dr. Blakeley. Finally, thank you to all of our listeners for tuning in to the ASCO Guidelines Podcast Series. To read the full guideline, go to www.asco.org/neurooncology guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast and be sure to subscribe so you never miss an episode. [MUSIC PLAYING]
An interview with Dr. Loretta Nastoupil from MD Anderson Cancer Center, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She discusses the identification, evaluation, and management of hematologic toxicities in patients receiving ICPis, including hemolytic anemia among others in Part 10 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines TRANSCRIPT [MUSIC PLAYING] SPEAKER: 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. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at ASCO.org/podcasts. My name is Brittany Harvey. And today, we're continuing our series on the management of immune-related adverse events. I am joined by Dr. Loretta Nastoupil from the University of Texas M.D. Anderson Cancer Center in Houston, Texas, author on Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy, ASCO Guideline Update, and Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy ASCO Guideline. And today, we're focusing on hematologic toxicities in patients treated with immune-checkpoint inhibitor therapy. Thank you for being here, Dr. Nastoupil. LORETTA NASTOUPIL: Thanks, Brittany. I'm happy to be here. BRITTANY HARVEY: Great. Then first I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Nastoupil, do you have any relevant disclosures that are related to these guidelines? LORETTA NASTOUPIL: Yes, Brittany. So I have received honorarium for participation in advisory boards from the following companies, including BMS/Celgene, Genentech, Janssen, Novartis, Merck, MorphoSys TG Therapeutics, and Takeda. And I've also received research funding support from BMS/Celgene, Gilead Kite, Genentech, Janssen, Novartis and Takeda. BRITTANY HARVEY: I thank you for those disclosures. Then let's get into what we're here today to talk about. So what are the immune-related hematologic toxicities addressed in this guideline? LORETTA NASTOUPIL: So it's important to recognize that hematologic toxicities that are immune-related as a result of immune therapy are infrequent occurrences. So it's important to recognize when they do occur and some of the unique workups given that they are so infrequent. So probably one of the most common is hemolytic anemia. It's important to recognize that these are cancer patients. And they may have multiple reasons for the development of acute or new onset anemia, but recognizing if they're on either checkpoint inhibitors or immune therapies, it's important to recognize that it might be spurred on as a result of immune-mediated anemia. We advise in terms of history and workup to consider whether or not they've been exposed to new drugs, whether or not they've had a recent insect or snakebite exposure. The recommended workup includes a CBC with also a peripheral blood smear to look for evidence of hemolysis or macroketosis. In addition, other hemolytic anemia workup includes evaluation for LDH, haptoglobin, reticulocyte count, bilirubin, and free hemoglobin. Other potential diagnoses on the differential include DIC, so a panel, including coags, PT, INR, and PTT, exploring autoimmune serologies, PNH screening, evaluation for infection such as viral or bacterial causes of hemolysis, and also consideration for bone marrow failure syndrome, including evaluation for potentially reversible causes, such as B12, folate, copper, parvovirus, iron, thyroid, infection, et cetera. G6PD level is helpful in the evaluation, as well as exploration as I mentioned of potentially new drugs that might be linked, including ribavirin, rifampin, dapsone, interferon, some of the antibiotics, such as cephalosporins, penicillins, NSAIDs, ciprofloxacin, for instance, et cetera. So as part of the workup, if we have excluded alternative causes and we think that the immune-checkpoint inhibitor might be the underlying cause of the autoimmune hemolytic anemia, then generally we will continue unless they have grade 2 or higher toxicity, which is generally a hemoglobin less than 10. In which case, we would recommend to hold the immune-checkpoint inhibitor, again, with significant anemia. So those with grade 2 or higher, you might consider initiating corticosteroids, including 1.5 to 1 milligram per kilogram per day until improvement. For grade 3 or higher-- so this is more severe anemia So hemoglobin is less than 8. Generally, we're recommending permanent discontinuation of the checkpoint inhibitor and potentially higher doses, including up to 2 milligrams per kilogram per day of prednisone or corticosteroid equivalent to speed up the recovery. In regards to transfusion requirements or consideration, we are suggesting you evaluate or consider your local or regional guidelines. We generally do not transfuse for a target hemoglobin greater than seven to eight. And we also recommend supplementation with folic acid. BRITTANY HARVEY: Great. And then beyond those recommendations for hemolytic anemia, what are the key recommendations for identification, evaluation, and management of acquired thrombotic thrombocytopenia purpura? LORETTA NASTOUPIL: Sure. So fortunately, TTP is quite rare, but, again, something that is worth exploring. Some of the challenges are in the clinical syndrome. And that it can mimic some of the other toxicities that are covered in other sections, particularly the neurotoxicity section. But essentially, for patients who have pretty dramatic change in platelet count, again, they may have additional clinical sequelae such as neurologic toxicity or adverse events. It's important to recognize that TTP might be an underlying cause, again, for patients who are on immune-checkpoint inhibitors. This is where a hematology consult early in the clinical course would be particularly of importance to recognize it and potentially to minimize offending agents. Drug exposure is always important, because many of these patients might have other drugs, in addition to their immune-checkpoint inhibitors, such as chemotherapy, sirolimus, tacrolimus, antibiotics et cetera. And so exploring offending agents is important. An ADAMTS13 level, an inhibitor titer, would be important to send if you're considering TTP, in addition to evaluating the peripheral smear, and the hemolytic anemia workup, as I just mentioned, including LDH, haptoglobin and reticulocyte count. Exploring infectious etiology, including CMV titers or serology, would be particularly helpful, an additional clinical evaluation, such as brain imaging with CT or MRI, echocardiogram, and EKG would be of help. For all grades of TTP, again, even with a clinical suspicion for the diagnosis, in addition to hematology consult, we recommend stabilizing the patient. That might require care in an acute care setting, making sure that they have adequate organ function and that this is stabilized. For grade 1 or higher, we recommend holding the immune-checkpoint inhibitor. And you might consider, again, initiation of corticosteroids with 0.5 to 1 milligram per kilogram per day of prednisone or an equivalent. For grade 3 or higher, we would, again, in addition to holding the checkpoint inhibitor and in conjunction with your hematology colleagues, you might initiate a therapeutic plasma exchange. Again, in accordance with existing guidelines, you may consider higher doses of steroids, including methylprednisolone 1 gram IV daily for three days. You could consider some additional supportive agents, such as rituximab or pembrolizumab if the ADAMTS13 level is less than 10 or less than 10% of normal and an inhibitor or elevated ADAMTS13 IgG has been detected. BRITTANY HARVEY: I appreciate you going through the details for TTP. So then, additionally, this guideline addresses aplastic anemia. So what are the key recommendations for identification, evaluation, and management of aplastic anemia? LORETTA NASTOUPIL: Yeah. So fortunately, again, these are quite rare situations. So with aplastic anemia, similar to what we've discussed in terms of workup of anemia, globally, it's important to explore potentially causes of, again, bone marrow failure syndrome. And aplastic anemia is one of those such causes. Exploration of a bone marrow biopsy in conjunction, again, with your hematology consult would be critically important, and exploring potentially reversible causes, again, such as deficiencies and important nutrients, viral etiologies, in addition to parvovirus, CMV, HHV-6 is important to consider and rule out. But I think the end of the day, a bone marrow biopsy and aspirate is going to be the most helpful assessment to ensure that aplastic anemia has been considered and worked up. In regards to management of aplastic anemia, we're going to hold the immune-checkpoint inhibitor. You may need to provide additional support such as growth factors. And close follow-up, I think is the most critical aspect of this. Sometimes we initiate patients on corticosteroids. We hold the checkpoint inhibitor. And then we may monitor them less frequently. Oftentimes, these patients with high malignancies are going to need to be followed very closely, sometimes weekly or multiple times a week. So in regards to management of aplastic anemia that might be immune mediated as a result of immune-checkpoint inhibitors and in conjunction with your hematology and colleagues, consideration of management might include administration of horse ATG and cyclosporine, but again transfusion support, growth factor support, even consideration for HLA typing and evaluation first. Stem cell transplantation might be appropriate, particularly for a young patient with minimal comorbidities. For grade 3 or higher, in addition to these considerations, we're going to hold the checkpoint inhibitor and monitor weekly for improvement. If no response, you might consider repeating immune suppression with Rabbit ATG plus cyclosporine or cyclophosphamide. And for refractory patients, consider eltrombopag plus best supportive care. BRITTANY HARVEY: Great. Thank you. Those are important notes on the management of aplastic anemia. So then, additionally, what are the key recommendations for the identification, evaluation, and management of lymphopenia? LORETTA NASTOUPIL: Yeah. I think one of the challenges with lymphopenia, it's common for patients who've had cancer-directed therapy, particularly things like chemotherapy. And so understanding whether or not this is a new onset after exposure to checkpoint inhibitors is one of the critical aspects, in addition to considering alternative causes. But for patients in which we do think the lymphopenia is a result of the immune-checkpoint inhibitor, we're not generally advising discontinuation or holding of the immune-checkpoint inhibitor, but it is important to consider best supportive measures, including whether or not patients might benefit from monitoring for reactivation of certain viral etiologies, including CMV and HHV-6, for instance, in addition to potential consideration for prophylactic strategies, such as PJP prophylaxis. Also, zoster reactivation might be something that these patients might indeed be at risk for. So as opposed to holding your checkpoint inhibitor and initiating things like corticosteroids, if we have excluded alternative causes and think lymphopenia is a result of the immune-checkpoint inhibitor or as immune mediated, ensuring that they are receiving best supportive care to mitigate some of their toxicity that may result as the result of the lymphopenia. BRITTANY HARVEY: Understood. And it's important to note for clinicians that management is different from a lot of the management of the other hematologic toxicities. So then the last hematologic toxicity that was addressed in this guideline was acquired hemophilia A. So what are those key recommendations? LORETTA NASTOUPIL: Acquired hemophilia A, again, fortunately is very rare and uncommon, but this is one situation where engagement of a hematologist, who is an expert in management of hemophilia, will be critical. So that would potentially be step one. In terms of laboratory assessment, that would be helpful, in addition to your CBC, where you're assessing things like platelet count, coagulation workup, including fibrinogen, PT, PTT, INR, that would be informative. Patients with acquired hemophilia A will likely have a prolonged activated PTT with a normal PT. So that might be one of the clues. Imaging would be helpful to ensure the patients don't have any signs of spontaneous bleeding or hematoma basis, such as MRI, CT, or ultrasound, if particularly they have any localizing symptoms. Medication review to look for alternative causes would always be helpful. And determination of the Bethesda unit level of inhibitor would be critical. In regards to management, we would hold the checkpoint inhibitor, initiate corticosteroids, transfusion support as indicated, and you want to treat the underlying acquired hemophilia with conjunction of a hematologist. For grade 2 or higher, this may require factor replacement. And the choice is usually based on the Bethesda unit of the titer. Administration of prednisone, in addition to rituximab 375 milligrams per meter squared weekly for four weeks or cyclophosphamide dosed at 1 to 2 milligrams per kilogram per day may be patient specific. And, again, that decision should be made in conjunction with your hematology consult. Prednisone, rituximab, and cyclophosphamide should be given for a minimum of five weeks. And factors should be prescribed to increase the level, particularly during bleeding episodes. And, again, the choice of the factor is based on the presence or absence of an inhibitor. For grade 3 or higher, we advise to permanently discontinue the immune-checkpoint inhibitor. These patients generally will be admitted for stabilization. They do require factor replacement. Bypassing agents may also be required, including factor VII. Caution should be taken in elderly patients and those with coronary artery disease. Corticosteroids, rituximab, and cyclophosphamide should also be considered, transfusion support, if they're having active bleeding. And if worsening or no improvement, you could consider adding cyclosporine or immune suppression to try and stabilize these patients. Again, acquired hemophilia A requires special clinical and laboratory expertise. This would require consult and potentially even transfer to a specialized center, and consultation with a hemophilia center should be initiated as soon as this is considered or confirmed. BRITTANY HARVEY: That's a great summary of these recommendations. The expert panel and you clearly put in a lot of work into these recommendations. So then in your view, how will these recommendations for the management of hematologic toxicities impact both clinicians and patients? LORETTA NASTOUPIL: I think the most important thing are disseminating this information. I think ASCO plays a critical role in helping clinicians first recognize some of the toxicities that are different from what we have traditionally seen with chemotherapy and may have different management strategies. So guidelines, such as this, are critically helpful. Podcasts, such as this, are incredibly helpful to get the information out, recognizing that all of us authors are more than willing to provide additional guidance and are willing to be contacted in this situation where someone's facing one of these unique and rare toxicities and would like some additional guidance in terms of further management. Hematologic toxicities are sometimes hard to distinguish or maybe potentially hard to recognize, given many of these patients may have been on prior chemotherapy agents, and anemia or thrombocytopenia may not be unusual, but recognizing if it's new or more severe than what has been seen previously and that, at least, consideration of an immune-mediated hematologic toxicity, be considered, because the management might be unique. And so I hope that we've outlined today some of the hematologic toxicities that are rare that may be seen with immune therapy and some of the strategies to work up alternative diagnoses and management if it is indeed immune-mediated toxicity. BRITTANY HARVEY: Definitely. And I really appreciate you going through these rare but very important toxicities. So thank you for your work on these guidelines and for taking the time to speak with me today, Dr. Nastoupil. LORETTA NASTOUPIL: Thanks, Brittany. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. Stay tuned for additional episodes on the management of immune-related adverse events. To read the full guideline, go to www.ASCO.org/supportive care guidlines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast, and be sure to subscribe so you never miss an episode. [MUSIC PLAYING]
An interview with Dr. Bianca Santomasso from Memorial Sloan Kettering Cancer Center, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” She reviews neurologic toxicities in patients receiving ICPis, such as myasthenia gravis, Guillain-Barre Syndrome, peripheral neuropathy, aseptic meningitis & encephalitis in Part 9 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines TRANSCRIPT [MUSIC PLAYING] SPEAKER: 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. BRITTANY HARVEY: Hello and welcome to the ASCO Guidelines Podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey. And today, we're continuing our series on the management of immune related adverse events. I am joined by Dr. Bianca Santomasso from Memorial Sloan Kettering Cancer Center in New York, New York, author on Management of Immune Related Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Therapy ASCO Guideline Update and Management of Immune Related Adverse Events in patients Treated with Chimeric Antigen Receptor T Cell Therapy ASCO Guideline. And today, we're focusing on nervous system toxicities in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Santomasso. BIANCA SANTOMASSO: Thank you for having me. BRITTANY HARVEY: Then I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Santomasso, do you have any relevant disclosures that are directly related to these guidelines? BIANCA SANTOMASSO: Yes, I'd like to disclose that I've served as a paid consultant for Celgene, Janssen Pharmaceutical, and Legend Biotech for advising them on the topics of T cell therapy side effects. BRITTANY HARVEY: Thank you. Then getting into the content of this guideline, what are the immune related nervous system toxicities addressed in this guideline? And what are the overarching recommendations for evaluation of these neurologic immune related adverse events? BIANCA SANTOMASSO: So neurologic immune related adverse events actually encompass a very diverse spectrum of neurologic syndromes that can occur as a complication of treatment with checkpoint inhibitors. So the spectrum that is covered by this guideline includes myasthenia gravis, Guillain-Barre syndrome, polyneuropathy, aseptic meningitis, and encephalitis. And although these are rarer than many of the other immune related adverse event types affecting other organ systems, they're increasingly being encountered due to more patients being treated with novel combinations of immunotherapies. And they're important to recognize, because along with myocarditis, they have generally more morbidity and even more mortality than irAEs affecting other organ systems. So it's important for clinical care providers to have a high index of suspicion for these events. Studies have suggested that these tend to occur in about 3% to 12% of patients, probably between 1% and 2% of patients developing severe events. So they're rare. But again, the events are probably more commonly seen in patients treated with combination checkpoint blockade. And we're increasingly seeing more combinations. So we should be on the lookout for these. Neurologic immune related adverse events can be divided into syndromes that affect the peripheral nervous system, so meaning the peripheral nerves, the neuromuscular junction, and muscle. So that would be Guillain-Barre syndrome, myasthenia gravis, and myositis. And those that affect the central nervous system, such as the brain, spinal cord, or leptomeninges. So those would be aseptic meningitis and encephalitis. The peripheral nervous system irAE appear to be more common than those affecting the central nervous system. And patients can present with a number of different symptoms that kind of relate to these syndromes. That can be as diverse as a headache to numbness, tingling, or focal weakness, such as a foot drop or facial weakness. You may see patients with severe altered mental status or personality changes or gait difficulty, walking difficulty, which could actually mean any number of syndromes. It's generally important to be aware that the timing of onset is generally early, a median of four weeks after the start of treatment, but can range anywhere from one week after the start of treatment to greater than a year. And because we know that cancer can spread to many parts of the nervous system, neurologic toxicity should be considered a diagnosis of exclusion. So that means that as part of the workup for neurologic immune related adverse events, it's imperative to rule out nervous system metastasis, stroke, and infection, which we know can occur at higher rates in patients with cancer. So for most neurologic immune related adverse events, diagnostic workup is similar. It should include MRI brain and/or of the spine, with and without contrast, and often a lumbar puncture for cerebrospinal fluid analysis, including cytology to rule out leptomeningeal metastasis. BRITTANY HARVEY: Thank you for that overview. In addition to those points for evaluation for all nervous system toxicities, what are the key recommendations for identification, evaluation, and management of myasthenia gravis? BIANCA SANTOMASSO: So for myasthenia gravis, presenting symptoms usually include fatiguable or fluctuating muscle weakness. It's generally more proximal than distal. And there's frequently ocular and/or bulbar involvement. So that means either ptosis, like a droopy eyelid, diplopia, or double vision, difficulty swallowing, dysarthria, facial muscle weakness, and/or head drop or neck weakness. Again, for any patient with new neurologic symptoms, an MRI of the brain or spine should be performed depending upon the symptoms to rule out central nervous system involvement by disease or some alternative diagnosis. And similar to idiopathic myasthenia gravis, acetylcholine receptor antibodies can be positive. So these should be checked. This is a blood test. But it's important to note that while these antibodies may be confirmatory, their absence does not rule out the syndrome. The rate of acetylcholine receptor antibody positivity in immune related myasthenia gravis has not been definitively established. So depending on the presentation, one might also consider sending a paraneoplastic panel for Lambert-Eaton myasthenic syndrome. The single most important point I'd like to make regarding suspected immune related myasthenia gravis is that orbital myositis and generalized myositis from immune checkpoint inhibitors can present similarly. For this reason, early neurology consultation and electrodiagnostic testing with repetitive stimulation or single fiber EMG becomes important and helpful to distinguish the two. And to make matters even more complicated, we've learned that there's an overlap syndrome, where patients may develop not only myasthenia gravis, but also myositis and/or myocarditis at the same time. So basically, the neuromuscular junction is affected. But the local muscle and myocardium, which is heart muscle that's kind of related, may be affected all at once. And this overlap of syndromes may increase disease severity and mortality. So they're important to recognize. So what this means is that when you encounter a patient with suspected myasthenia gravis, you should also be checking CPK, muscle enzymes, aldolase to evaluate for myositis, and troponin and electrocardiogram to evaluate for myocarditis. And this should be done even if there are no obvious symptoms. So onto the treatment of myasthenia gravis, this is similar to the management of the idiopathic form. Therefore, it's helpful to have the involvement of a neurologist. The immune checkpoint inhibitor therapy should be held. And patients with mild symptoms are often started on pyridostigmine and corticosteroids. And patients with more severe symptoms should initiate IVIG or plasmapheresis. And patients with more severe symptoms may need to be admitted to the hospital. So that their neurologic and pulmonary status can be monitored closely for improvement. Some patients may require ICU level of monitoring. And considering adding rituximab if symptoms are refractory, and often, as symptoms improve, the steroids can be de-escalated. BRITTANY HARVEY: Understood. Those are all very important points for clinicians to consider. So then following that, what are the key recommendations for identification, evaluation, and management of Guillain-Barre syndrome? BIANCA SANTOMASSO: So Guillain-Barre syndrome, like myasthenia gravis, also presents with weakness. Most often, patients present with a progressive ascending muscle weakness. The syndrome can start with sensory symptoms or neuropathic pain that can be localized to the lower back and thighs. In addition to the classic ascending weakness, there may be facial weakness, double vision, numbness or tingling in the hands or feet, loss of balance, and coordination. And shortness of breath may occur due to respiratory muscle weakness. The autonomic nerves can also be affected and can present as new severe constipation or nausea, urinary problems, or orthostatic hypotension. The reflexes are often reduced or absent, deep tendon reflexes. So again, as for all of the syndromes, early involvement by a neurologist is recommended, if possible. Usually, MRI imaging of the spine is important to rule out spinal cord compression. And it also may show cauda nerve thickening or enhancement, which can occur with this syndrome. And the second aspect is cerebrospinal fluid analysis is important for diagnosis. This is important really for ruling out leptomeningeal metastasis, since that could present similarly. And often, what can be seen in GBS is an elevated protein level in the cerebrospinal fluid. In addition, unlike idiopathic GBS, there can be an elevated white blood cell count in the cerebrospinal fluid. Electrode diagnostic testing can also be helpful for confirmation, and serum tests for antiganglioside antibodies, and a paraneoplastic antibody workup may also be considered. Bedside pulmonary function test and swallowing evaluation should be performed if there's a concern for respiratory or swallowing dysfunction. And some patients do need to have inpatient admission and monitoring if symptoms are severe or if they appear to be progressing from mild. For management, the checkpoint inhibitor therapy should be held. And patients are most often treated with IVIG or plasmapheresis. Corticosteroids can be added to the IVIG or plasmapheresis. These are not usually recommended for idiopathic Guillain-Barre syndrome. However, in immune checkpoint inhibitor related forms, a trial is reasonable. And steroids are usually given at a higher dose for five days and then tapered over several weeks. BRITTANY HARVEY: Understood. I appreciate that overview. So then what are the key recommendations for identification, evaluation, and management of peripheral neuropathy? BIANCA SANTOMASSO: So peripheral neuropathy, or polyneuropathy, is a rare but likely underreported complication of immune checkpoint inhibitor therapy. So in the large databases and meta-analyses, those have really focused on Guillain-Barre syndrome for reporting. But other types of neuropathies, such as painful length dependent sensory and motor axonal neuropathies, or polyradiculopathies or sensory neuropathies do occur after immune checkpoint inhibitors and are probably under-recognized. So evaluation of immune related neuropathy should include neurology consultation to guide the neurology phenotype determination and also the workup. The evaluation primarily relies on a combination of electrodiagnostic studies, serologic tests, and MRI neuroimaging. Because peripheral nervous syndromes can overlap, screening for neuromuscular junction dysfunction with electrodiagnostic testing and myopathy is recommended for any patient who presents with at least motor symptoms that are thought to be peripheral. Serum testing can be helpful for ruling out reversible causes of neuropathy. Spinal imaging is recommended to exclude metastatic disease. And for management, it usually involves holding the checkpoint inhibitor in mild cases, using neuropathic pain medication or steroids in more severe cases. And very severe cases that kind of resembled GBS would be managed as per the GBS algorithm with IVIG or plasmapheresis. BRITTANY HARVEY: Understood. And it's key to look out for those overlapping adverse events. So then following that, what are the key recommendations for aseptic meningitis? BIANCA SANTOMASSO: Right, so now we're getting into the central nervous system toxicity. So aseptic meningitis is an inflammation of the meninges. And it can present with headache, photophobia, neck stiffness. Patients can have nausea, and vomiting, and occasionally fever. The mental status is usually normal. And in patients presenting with headache, which in isolation, could suggest an aseptic meningitis, it's important to evaluate if they have any confusion or altered behavior, which might suggest an encephalitis. And this distinction is important, because suspected encephalitis triggers a different workup, which we'll be discussing later, and also even different management. So the workup for aseptic meningitis includes neuroimaging, usually an MRI of the brain. And on that imaging, we sometimes see abnormal leptomeningeal enhancement. It's important not to assume that this is cancer and to do a lumbar puncture to evaluate cerebrospinal fluid both for inflammation and to exclude other causes of meningeal disease, particularly neoplastic and infectious causes. So cytology, Gram stain, and culture, and other infectious studies should be negative. And it's recommended that empiric antibiotics or antiviral therapy be considered to cover for infectious meningitis until the cerebrospinal fluid results return negative. What's seen in the cerebrospinal fluid in aseptic meningitis is typically reactive lymphocytes, but also neutrophils or histiocytes may be prominent on the cytology. And while the symptoms can be severe, sometimes requiring hospitalization, the management of this entity, these are usually quite treatable. Aseptic meningitis generally responds very well to corticosteroids. So management involves holding the checkpoint inhibitor. And you can often get away with starting a fairly modest dose of corticosteroids, such as oral prednisone, 0.5 to 1 milligram per kilogram or the equivalent. And steroids can usually be tapered over two to four weeks. BRITTANY HARVEY: Great, thank you for reviewing those recommendations. So then you just mentioned the distinction of aseptic meningitis and encephalitis. So what are those key recommendations for identification, evaluation, and management of encephalitis? BIANCA SANTOMASSO: So in encephalitis, the mental status is not normal. It's characterized by, really, an acute or subacute confusion, altered mental status, altered behavior, memory deficits, including working memory and short-term memory. There can be, as associated symptoms, headaches, new onset seizures, psychiatric symptoms, which can include delusions or hallucinations. There could be weakness, sensory changes, imbalance, or gait instability, along with the mental status changes. And so similar to aseptic meningitis, the other central nervous system toxicity, it's important to distinguish encephalitis from other causes of altered mental status, such as CNS metastases, stroke, or infection. And as for the other syndromes, it's very helpful to have neurologic consultation early, if possible. An MRI of the brain is critical. And in addition, MRI of the spine may be obtained to evaluate for inflammatory demyelinating ischemic or metastatic lesions. In immune related encephalitis, MRI brain imaging may reveal T2 flare changes, typical of what can be seen in idiopathic autoimmune or limbic encephalitis. But most often, the MRI imaging is normal. So in this situation, a lumbar puncture for CSF studies to evaluate for evidence of inflammation can be very helpful. You can expect to see either a lymphocytic pleocytosis or an elevated protein, or CSF restricted oligoclonal bands. CSF analysis is also helpful for excluding other causes of encephalitis, particularly viral encephalitis. So HSV, Herpes Simplex Virus, or varicella zoster virus encephalitis should be ruled out and treated with antivirals while the tests are pending. So typically, these entities can be excluded by PCR testing for HSV and VZV. Electroencephalogram, or EEG, can also be helpful for revealing subclinical seizures or status epilepticus, which can occur as a complication of encephalitis or as a cause of persistently depressed sensorium. But these are not specific to encephalitis. Other testing that's done includes screening metabolic tests to look for alternative etiologies. And for this entity, serum and CSF autoimmune antibody evaluation should be sent to assess for malignancy associated neurologic syndromes. And your neurologist can help you with the workup and management, in particular which tests to send. There have been reported cases of antibody positive checkpoint inhibitor related encephalitis. For management, in contrast to aseptic meningitis, these are generally not as steroid sensitive. So you often have to treat with either higher steroid doses, even pulsed steroid doses, along with IVIG or plasmapheresis. If no improvement, escalation to rituximab and cyclophosphamide can be considered, with the assistance of neurology. This management guidance is taken from how to treat autoimmune encephalitities that are not related to checkpoint inhibitors. Unfortunately, these can be difficult to treat. The response may only be partial. So this is one area in need of better understanding of best therapeutics. BRITTANY HARVEY: OK, thank you for reviewing that and pointing out where there's future research needed as well. And I appreciate your reviewing the recommendations for each of these neurologic immune related adverse events. So then to wrap us up, in your view, how will these recommendations for the management of nervous system toxicities impact both clinicians and patients? BIANCA SANTOMASSO: Yeah, so I think this is a daunting list of toxicities. But I'll say that in most situations, the immune checkpoint inhibitor side effects are often manageable and reversible with proper supportive care. They can be serious, and they require close vigilance and prompt treatment and identification. But by knowing what to look for in early identification, that allows early intervention, which is really the key to reversibility and the best outcomes. So having these toxicities on your differential diagnosis is critical. And I think these guidelines really help inform both clinicians, and care providers, and patients on what the possible manifestations are. So we believe this guideline and its recommendations will help members of clinical teams with the recognition and the management of these unique toxicities. And again, it's timely recognition and early intervention that helps patients, really, by increasing their safety with early management. BRITTANY HARVEY: Great, well, thank you for your work on these guidelines and for taking the time to speak with me today, Dr. Santomasso. BIANCA SANTOMASSO: My pleasure. Thank you so much. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines Podcast series. Stay tuned for additional episodes on the management of immune related adverse events. To read the full guideline, go to www.asco.org/supportive care guidelines. You can also find many of our guidelines and interactive resources in the free ASCO Guidelines app, available in iTunes or the Google Play store. If you have enjoyed what you've heard today, please rate and review the podcast. And be sure to subscribe. So you never miss an episode. [MUSIC PLAYING]
In our newest segment, one which reflects on our complete lack of judgement and discernment, we present LIVE SINGING, the segment that features various singers "singing" (yes, that word was intentionally placed within quotation marks!) some of your favorite songs! On today's show, "Cannabis Carl" and "Paranoid Pete", came in to sing "HOW DO YOU KEEP THE MUSIC PLAYING?". As Al often says, what could POSSIBLY go wrong??? Enjoy!
(I Do Not Own the Rights to the Music Playing in this Podcast) I remember the first time I started my self-care Journey. I was nervous when I realized that people were leaving my life. I truly felt as if I was on a plane I thought about when the flight attendant begun to give us the safety speech about what to do in the event of an emergency. This was an eye opening for me, as they stated if the plane lose cabin pressure, an oxygen mask would come down in front of us and that we should put the mask on ourselves First. As I thought about this, I was in shock I thought to myself if I'm on this plane with my son I'm going to make sure he is taking care of first. It was a part of who I was to take care of my son first, I could actually see myself bouncing out of my seat to go help my son. It was then that I realized that if I didn't take care of Me first. I would not have any life to give others. I literally had an epiphany when I thought about what you need to do in the event of an emergency on the plane. As a matter of fact that moment I began my self-care journey and realized that before I can commit to taking care of others including my son I have to take care of me. Please follow JS Self-Care on all Social Media Platforms . https://linktr.ee/Jsselfcare Disclaimer: This podcast is for educational purposes only. The host claims no responsibility to any person or entity for any liability, loss or damage caused or alleged to be caused directly or indirectly as a result of use of the application or interpretation of the information presented in this podcast.
Glasses/sunglasses with built-in speakers have been a thing for a shockingly long time now. They've never been particularly popular, mind, but at the very least, they're an interesting enough concept for companies to continue taking a sporadic stab at the category, whose primary appeal seems to be not being forced to purchase both glasses and […]
CT Rowe shares stories about what it was like to work for the National Ballet of Canada Orchestra, how she ended up playing what she did there and what she's playing now - CT is a remarkable person who tells me that she lived her whole live practicing how to live her life here in the country - from the glamorous concert halls of the world to a lovely home on Fraser Lake. We talk about it all. I love that she picketed Carnegie Hall. She'll tell you why. And an added treat, the music at the end is CT playing. Enjoy! #BLACKLIVESMATTER And last week was a hard week for many, especially people of colour who are exhausted from having to explain again and again how their lives are in peril by the police and the system of anti-black racism that is destroying lives. Give a listen to these podcasts - Black people talking about Black Lives. We've been told it will get better - it won't if we don't do anything. I am posting these links in the hope that they will amplify the voices of Black people at a time when we should all be listening. Things have to change. Canadian Podcasts I highly recommend Sandy and Nora Talk Politics Podcast. Sandy Hudson was one of the co-founders of Black LIves Matter Toronto and she and co-host Nora Loreto talk about important issues - they hold no punches and are a refreshing voice and reality check. Sandy and Nora Talk Politics The Globe and Mail's Podcast Colour Code Podcasts from the USA 1. Still Processing Podcast about Colin Kaepernick 2. The Daily Podcast Systems that Protect the Police 3. Code Switch Podcast A Decade of Watching Black People Die --- Send in a voice message: https://anchor.fm/roy-mitchell5/message
[smart_track_player url=”http://traffic.libsyn.com/7figureceo/7CEO_049-Your_Perfect_Day_With_Andy_Levine.mp3″ title=”7CEO 049: Your Perfect Day with Andy Levine” artist=”Casey Graham” social=”true” social_twitter=”true” social_facebook=”true” social_gplus=”true” ] Andy Levine started his company, Sixthman, 15 years ago which takes fans and bands on vacation together on cruise ships. He sold it in 2012 and continued to run it until 2016 when he stepped into the role of Chairman. He was a previous guest of the podcast on episode 28. Today we're taking a different approach to the podcast and talking about some more personal stuff that leaders of an organization deal with. Andy shares about how he has developed a rhythm for his days that is best for him, his family and his leadership. LINKS Andy's first episode on The 7-Figure CEO Podcast: Episode 28 Productive App – Productive habits and daily goals tracker Email your top take-aways and learnings to Casey@CaseyGraham.com Apply for a Breakthrough Call with Casey: CaseyGraham.com/Action TOP TAKE-AWAYS Andy journaled for a year and logged what he did with his time and what was going on with his family. He started on the journey to help build the optimal day for him and his family. He used his phone to write about 300 words a day to describe what happened during the day, how he spent his time and how the day went. Through this he developed an ideal rhythm for him. YOUR PERFECT DAY IN THREE PARTS 1. MORNINGS FOR ME – Exercise – Crossfit, Yoga, swimming or running – Learning – Listening to a podcast or reading – Music – Playing guitar or piano – Mindfulness – Identify five things, touch four things, pick out three unique sounds, two unique smells and one unique taste (which helps with anxiety) – Nutrition – Make a good food choice first thing in the morning To Business Owners and Entrepreneurs: You CAN take time for you! You don't have to buy into the idea that you have to work so hard that you neglect yourself and those you love! If you're leading people, you're going to do a better job if you show up feeling confident about yourself and ready to connect with and lead people! You don't have to always be the first person in the office! Anxiety is a big issue that entrepreneurs go through and maybe it's a result of a noisier, busy world that our bodies aren't able to process everything that's coming in. Physical exercise is one of the best therapies for anxiety. 2. DAYS FOR OTHERS Each of us have gifts that should be used to help others. As the leader of an organization, you should plan to spend the first hours of your day serving others – helping them achieve their weekly wins. You can also invest in your customers to serve them! If you're investing in yourself first then you will have the energy and bandwidth to serve others for a few hours. It's also very important to expand your network and go out and meet with people. Through getting out of your everyday, office routine to meet with others and go to conferences, you help others, hear of opportunities, and innovate new ideas for your business and life. 3. NIGHTS FOR US This is meeting your family or loved ones in a shared orbit of interest. Ask your loved ones what they enjoy doing just with you? By asking them you take the guess work out of how to best love your family and friends. By showing initiative, you communicate they are important. There are three big relationships we have that should be prioritized. Create a daily rhythm to take care of these relationships and that works well for you! 1. Ourselves – This is probably the hardest relationship because we know everything about us. 2. Others – customers, employees, peers 3. Significant relationships – those you love and friends Feeling Stuck In Your Business? I'm currently offering free 30-minute Breakthrough Calls to help business owners, presidents and CEOs with their current business challenge. If you have over $400K in annual revenue and would like help, schedule your free Breakthrough Call today.
6 AM - 1 - Vincent is meeting the Fair Rebecca's parents manana; Marshall lost his smartphone; Openings. 2 - Early COW; MailBag. 3 - The News with Marshall Phillips. 4 - The Palestinians are really mad right now.
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