Podcasts about nccn

Physician and clinical researcher Chris Apfel discusses his article, "Functional precision oncology: a game changer in cancer therapy." Chris explains that functional precision oncology takes a highly personalized approach by testing a patient's live tumor cells outside the body (ex-vivo) against a panel of cancer drugs to directly observe which treatments are most effective against that specific cancer. This method, he argues, can significantly improve cancer response rates and survival while reducing costs and unnecessary side effects, by moving beyond the limitations of standard pathology (which identifies cancer type but not optimal treatment) and genomic sequencing (which identifies mutations but provides actionable targets for only a minority of patients). Chris recounts the history of functional testing, its initial promise, its decline with the rise of next-generation sequencing, and its current resurgence, supported by studies demonstrating its high predictive accuracy for clinical outcomes. Despite its potential to complement genomics and truly personalize care, he notes that functional precision oncology faces slow adoption due to its general absence from standard NCCN treatment guidelines, hospital restrictions on external tissue testing, and a systemic preference in health care for standardization over innovative, individualized approaches. Chris strongly encourages patients, particularly those facing difficult or unresponsive cancers, to educate themselves about functional precision oncology and actively advocate for access to these tests. Our presenting sponsor is Microsoft Dragon Copilot. Want to streamline your clinical documentation and take advantage of customizations that put you in control? What about the ability to surface information right at the point of care or automate tasks with just a click? Now, you can. Microsoft Dragon Copilot, your AI assistant for clinical workflow, is transforming how clinicians work. Offering an extensible AI workspace and a single, integrated platform, Dragon Copilot can help you unlock new levels of efficiency. Plus, it's backed by a proven track record and decades of clinical expertise and it's part of Microsoft Cloud for Healthcare–and it's built on a foundation of trust. Ease your administrative burdens and stay focused on what matters most with Dragon Copilot, your AI assistant for clinical workflow. VISIT SPONSOR → https://aka.ms/kevinmd SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended

JCO Editorial Fellow Dr. Lauren Shih and JCO Associate Editor Dr. Stephanie Wheeler discuss the ASCO 25 Simultaneous Publication paper "Use of Low-Value Cancer Treatments in Medicare Advantage Versus Traditional Medicare." Transcript The guest on this podcast episode has no disclosures to declare. Dr. Lauren Shih: Hello, and welcome to our 2025 ASCO annual meeting series where we cover some of the top JCO papers published simultaneously with their abstract presentations at this year's meeting. I'm your host, Dr. Lauren Shih, JCO editorial fellow, and I'm joined by JCO Associate Editor Dr. Stephanie Wheeler to discuss the Journal of Clinical Oncology article and abstract presentation "Use of Low-Value Cancer Treatments in Medicare Advantage Versus Traditional Medicare." Let's start with the relevance of the article. Dr. Wheeler, can you explain this to our listeners? Dr. Stephanie Wheeler: Thank you so much. Let's get right into it. So this article is really about understanding different types of Medicare plans and what we should expect to see in terms of their use of low-value treatments for cancer patients. So, as Medicare really is focused on trying to limit the use of low-value cancer treatments, we really need to better understand the drivers of variability. So we know that many cancer patients have multiple treatment options available to them. We also know that the vast majority of older adults beyond age 65 are insured by Medicare, and about half of them are on Medicare Advantage plans, which are serviced by private insurance. And private insurance companies in this case are receiving capitated payments for Medicare beneficiaries to manage their service utilization and reduce costs. So, with respect to Medicare Advantage versus the traditional fee-for-service Medicare, it's not really been known to what extent low-value treatments are differentially used by these types of plans for cancer patients. And so that was really the focus of this article. What the authors found is that across six different types of treatments, in general, the folks who were enrolled in Medicare Advantage plans had reduced use of low-value treatment. So that's a good sign for Medicare beneficiaries. And although the relative difference in that use was somewhat low, this translates to a significant number of Medicare enrollees across the country not receiving these low-value treatments. And of course, this translates to considerable savings at the society level. Dr. Lauren Shih: Are there any additional key results that we should review? Dr. Stephanie Wheeler: Yeah. So I'll tell you just a little bit more about the methods and also their findings. So they looked at six different low-value treatments, and this was in, again, 100% of national Medicare enrollees from 2015 through 2021. So the six low-value treatments that they examined were the use of G-CSFs among patients receiving low-risk chemotherapy and denosumab for those who had castration-sensitive prostate cancer. Then they also looked at four high-cost treatments, including using nab-paclitaxel instead of paclitaxel for patients with breast or lung cancer; second, adding bevacizumab to carboplatin plus paclitaxel for ovarian cancer; third, using brand-name drugs instead of generics when generics were available; and fourth, using biologics instead of biosimilars when biosimilars were available. And these are all, by the way, non-recommended treatments according to a variety of guidelines, including NCCN and ASCO's Choosing Wisely guidelines. So they used the Medicare claims data to examine use of these regimens. They also analyzed results by type of Medicare Advantage plan, whether people were enrolled in a health maintenance organization plan, or an HMO, or a preferred provider organization plan, or a PPO. They also looked at the largest Medicare Advantage insurers—including Aetna, Blue Cross Blue Shield, Cigna, Humana, and UnitedHealth—and limited their analyses to those that had complete encounter data. And what they found across the board is that the enrollees in Medicare Advantage plans generally had lower use of these low-value treatments. And the largest differences between Medicare Advantage and traditional Medicare plans were in the outcomes, including G-CSF use and using denosumab for castration-resistant prostate cancer, and then the combination of bevacizumab, carboplatin, and paclitaxel versus carboplatin and paclitaxel. And all of these had a change in use ranging from about 19% change to 24% change in use. This is significant as a field as we look at ways in which different plan organization can influence use of treatments, particularly given the excess cost of cancer care. This is something we really want to pay attention to. So I'd encourage folks to look more closely at the results by treatment type as well as the results by plan type to see a little bit more about what was going on across different plan types. Dr. Lauren Shih: Great. And are there any outstanding questions that need to be answered? Dr. Stephanie Wheeler: Yes, there always are, of course. I think the study has several strengths that are worth noting. First, they have 100% of Medicare enrollees, so there's national coverage there, which is, you know, quite outstanding. They also use an appropriate choice of analysis to help deal with some of the selection. So they use inverse probability of treatment weights, and they control for practice and county indicators to try to get some realistic adjustment for the selection that happens in terms of how patients are enrolled in different Medicare Advantage versus traditional fee-for-Medicare plans. These statistical approaches are a good idea, but they are limited by the observed variables that we can use for these kinds of adjustments. And so any unobserved—confounding or any unobserved factors that would influence selection in these plans aren't going to be captured well. So preferences, for example, that patients may have about different types of plans when they're insuring themselves and their families may not be captured. Second, the data that are used are only encounter data from those plans with complete records. That may mean that smaller Medicare Advantage insurers or those that don't have as comprehensive records are not included. So this may not be reflective of their practice patterns. And then third, of course, this only looked at six different low-value cancer treatments. It remains to be seen whether this kind of finding extends to other types of low-value cancer treatments, and that's an opportunity for future study. Finally, I would say that we don't exactly know why these patterns exist. It could be that Medicare Advantage plans have different approaches to prior authorization. They could have more in-house quality control and management to really understand, among their population for whom they're receiving Medicare Advantage payments, to really look at care quality and assess Choosing Wisely guidelines. We don't know exactly how that's playing out. And so we need additional data to really figure out what's working here and what are opportunities for future policy and payment innovations that can further reduce low-value care. Dr. Lauren Shih: Great. Thank you so much, Dr. Wheeler, for speaking to us about the JCO article, "Use of Low-Value Cancer Treatments in Medicare Advantage Versus Traditional Medicare." We really appreciate your insights. Dr. Stephanie Wheeler: Thanks for having me. Dr. Lauren Shih: Join us again for the latest simultaneous publications from the ASCO 2025 Annual Meeting. Please take a moment to rate, review, and subscribe to all ASCO podcast shows at asco.org/podcasts. Until then, enjoy the rest of ASCO 2025. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

In this inspiring episode of SHE MD, hosts Mary Alice Haney and Dr. Thaïs Aliabadi welcome Dr. Mindy Goldman and Joanna Strober, founders of MIDI Health. Dr. Goldman shares her expertise on individualized hormone therapy approaches, while Strober explains how Midi Health is revolutionizing access to menopause care through telemedicine and more. The episode provides valuable insights for women navigating perimenopause and menopause, as well as healthcare professionals seeking to improve their understanding of hormone therapy. Access more information about the podcast and additional expert health tips by visiting SHE MD Podcast and Ovii. Sponsors: Purely Elizabeth: Visit purelyelizabeth.com and use code SHEMD at checkout for 20% off. Purely Elizabeth. Taste the Obsession.Timeline: Timeline is offering10% off your order of Mitopure. Go to timeline.com/SHEMD. Saks: Shop Saks.comCymbiotika: Go to Cymbiotikia.com/SHEMD for 20% off your order + free shipping today.David's Protein: David is giving my listeners an exclusive offer – buy four cartons and get the fifth free at davidprotein.com/shemdMIDI HEALTH'S KEY TAKEAWAYS:Evaluate Breast Cancer Risk: If you have a family history or genetic predisposition, consult with a specialist about hormone therapy and preventive measures.Consider Vaginal Estrogen: For vaginal dryness, vaginal estrogen can help, even if you have a history of breast cancer or a breast cancer patient.Assess Heart Health: Get a coronary calcium scan to evaluate heart health before starting hormone therapy. Consider Hormone Therapy Under The Age of 60: Discuss the potential benefits of bioidentical hormones with your doctor, 10 years before your menopause. The timing hypothesis says that the benefits of hormones tend to outweigh the risks if you start people within that 10-year window.Explore Non-Hormonal Alternatives: Lifestyle, dietary changes, and non-hormonal alternatives like CBT can help in managing menopausal symptomsIN THIS EPISODE: (00:00) Intro(01:27) How the Midi Health Founders got together and started Midi Health(06:50) HRT for Breast Cancer Patients(12:16) Hormones and breast cancer risk explained(24:55) How does Midi Health work?(33:16) Non-hormonal options for breast cancer patients(46:33) Can you use estrogen on your face?(48:18) When should you be on hormones and for how long?(57:51) Do you prefer estrogen patch or gel? (59:05) Testosterone, HRT, and menopause to improve libido(01:07:53) How to join Midi Health?RESOURCES:Visit MIDI Health website joinmidi.com: http://joinmidi.comJoanna Strober's LinkedIn: https://www.linkedin.com/company/midi-health/mycompany/Mindy Goldman's LinkedIn: https://www.linkedin.com/in/mindy-goldman-9b7a8930/GUEST BIOGRAPHY:Joanna Strober is the CEO and founder of Midi Health, a virtual care platform for women in perimenopause and menopause. The company brings expert care, covered by insurance, to women nationwide. Prior to Midi, Joanna founded Kurbo, the first digital therapeutic for childhood obesity, which was scaled to help tens of thousands children worldwide and the company was successfully sold to Weight Watchers in 2018. Prior to diving into digital health, Joanna spent more than 20 years in direct private equity and venture capital investing in health and consumer companies including a number of notable consumer internet companies, including BlueNile, eToys, Babycenter, HotJobs and Flycast.Joanna is the author of the book Getting to 50/50, a primer on how women can succeed and thrive at work and at home. She has spoken extensively to corporate and graduate school audiences on the topic of women and leadership. She was also named to the Forbes 50 over 50 list of top Innovators in 2023.Mindy Goldman is the Chief Clinical Officer at Midi Health and a Clinical Professor Emeritus in the Department of Obstetrics and Gynecology and Director of the Gynecology Center for Cancer Survivors and At-Risk Women Program at the University of California, San Francisco. As Midi's Chief Clinical Officer, Dr. Mindy Goldman brings her decades of experience as an OB/GYN to all our patient care, but survivors of breast cancer and at-risk women are a special focus for her. Dr. Goldman is a nationally recognized expert in the menopausal symptoms that come with treatment for breast cancer, and how to improve them safely and effectively. Dr. Goldman has created a unique program that bridges gynecology and breast oncology, and provides breast cancer survivors with care that is focused on quality of life and addresses specific women's health needs while undergoing cancer treatment. She is a nationally recognized expert in this field and in 2012 authored the American College of Gynecology (ACOG) Technical Bulletin that provides comprehensive clinical guidelines on the management of gynecologic issues in women with breast cancer. She is on the survivorship panel for the National Comprehensive Cancer Network (NCCN) and is the Sub-committee Chair for the panels on sexual functioning and menopause and helped author the NCCN management guidelines in these areas.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Live from AUA2025: Advances in ADT Program CME Available: https://auau.auanet.org/content/LiveFromAUA2025#group-tabs-node-course-default1 At the conclusion of this CME activity, participants will be able to: 1. Employ the latest AUA and NCCN guidelines (Version 1.2025) related to Androgen Deprivation Therapy (ADT) into practice 2. Evaluate clinical outcomes, efficacy, and safety profiles of different types of ADT including oral and parenteral LHRH agonists and GnRH receptor antagonists in different treatment settings. 3. Compare testosterone recovery, treatment efficacy, safety profiles, and patient preferences between different modalities of ADT. 4. Recognize common side effects associated with different types of ADT and its combination therapies as well as strategies to mitigate these adverse effects to improve patient outcomes. 5. Implement a multi-disciplinary approach in managing advanced prostate cancer with ADT. 6. Evaluate the future directions and ongoing research that may impact the use of ADT in clinical practice.

Dr. John Sweetenham, Dr. Larry Shulman, and Dr. Rebecca Maniago discuss the integration of clinical pathways and decision support tools into the cancer center workflow, challenges to implementation at the point of care, and the promise of AI to further unlock these tools for clinicians. TRANSCRIPT Dr. John Sweetenham: Hello, I'm Dr. John Sweetenham, the host of the ASCO Daily News Podcast. Over the last decade or so, there has been a great deal of work and a lot of discussion about the implementation of oncology clinical care pathways at the point of care, which are designed to reduce variability in care, reduce costs, and improve the quality of care and outcomes. Although clinical pathways aim to guide treatment decisions, current data suggests that the utilization of these pathways at the point of care is very low. There are many reasons for this, which we will get into on the episode today.   My guests today are Dr. Larry Shulman and Rebecca Maniago. Dr. Shulman is a professor of medicine at the University of Pennsylvania Abramson Cancer Center. He's also the immediate past chair of the Commission on Cancer and serves on the National Cancer Policy Forum of the National Academies of Sciences, Engineering and Medicine. Rebecca Maniago is the director of clinical oncology at Flatiron Health, a technology platform that collects and analyzes real-world clinical data from electronic health records to facilitate decision making and research.  Our full disclosures are available in the transcript of this episode. Larry and Rebecca, welcome to the ASCO Daily News Podcast and many thanks for being here.  Dr. Larry Shulman: Thank you, John.  Rebecca Maniago: Thank you for having me.  Dr. John Sweetenham: Larry, I'm going to start out, if I may, with a question for you. You and I, in a previous podcast, have discussed some of these issues regarding pathway implementation before. But to start out with, it's certainly, I think, helpful for the listeners to remind us all of what are the benefits of oncology clinical pathways and why are we still talking about this 10 years or more on.  Dr. Larry Shulman: Yeah, and that's a great question, John. I think the good news is, and all of us who live in the oncology sphere know this, that there's been tremendous progress in cancer therapies over the last decade. But what that has entailed is the introduction of many new therapies. Their complexity is becoming really very tough for people to manage.  And so what we have are oncologists who are really trying to do their best to deliver care to patients that will give them the best chance for survival and quality of life. But it's really, really hard to keep up with everything that's happening in oncology in the context of what we all know is a very busy clinic schedule. Lots of patients coming through and decisions need to be made quickly. Pathways really could help us to guide us into recommending and delivering the best therapies for our patients for a particular disease. You know, cancer is complicated. There are many different types and there are many different therapies. It's just a lot to deal with without some assistance from pathways or pathway tools.  Dr. John Sweetenham: Thanks, Larry. So, knowing that's the case and knowing that these tools reduce variability, improve costs, improve quality of care as well. Starting with you again, Larry, if I may, why do you think it's been so difficult for so many oncologists to use these pathways effectively at the point of care?  Dr. Larry Shulman: So, I just wanted to step back a little bit. There are very extensive guidelines that tell us what the best therapies are for really all of the cancers. These guidelines come from the National Comprehensive Cancer Network or NCCN and the American Society of Clinical Oncology or ASCO and other professional organizations. And they're there. They're there, in free information off their websites.  But the problem is how to translate those pretty dense documents into something that will work in the clinic for a patient, for the physician who's working in the electronic health record. And the tools that are available, and there are a number of tools that can integrate with electronic health records, are expensive. You need to purchase them from the vendor and there are yearly fees.  And they're also difficult to implement. You need to work with the vendor to integrate them into your own rendition of your electronic health record. And there's a lot of customization that needs to be done. So, it's a financial challenge and it's also a time challenge for people to integrate these tools into their workflow, into their electronic health records.  Dr. John Sweetenham: Thanks, Larry. So speaking from my own past experience of pathway implementation, it certainly has been a major challenge for the reasons that you mentioned and also because of the, I think resistance may or may not be too strong a word, of many of the clinicians to use these for a number of reasons, part of which are the time it takes, part of which many of them feel that the pathways aren't really changing decisions that they might make anyway. So, you know, the uptake of pathway utilization, even in those centers which have been successful in getting something installed and plugged into their EHR, on the whole, hasn't been as good as it could have been. So maybe I'll turn to you, Rebecca, because I know that this is something that you've worked on a lot.  And it's a kind of double-barreled question. I think the first part of it is, you know, what do you think are the major roadblocks to high physician uptake in the use of these pathways platforms? And maybe you could talk a little bit about what the various software platforms do to make them more physician-friendly and to enhance utilization right on the front line.  Dr. Rebecca Maniago: Yeah, that's a great question. And so, you know, I've worked with a number of customers and physicians over the past five and a half years on implementing these pathways. And the number one pushback is really about the time it takes in the workflow. So, if I had a dollar for every time I heard “every click counts,” I'd be a rich person and it does come down to clicks. And so, you know, as a software vendor, we really have to focus on how do we reduce that friction?  How do we make sure that the clicks we are asking for are the ones that actually matter? And how do we continue to streamline that process? And so, you know, while there is a fine balance, because as part of a Pathways platform, at the end of the day, we do need to understand some data about that patient. You need to understand the clinical scenario so you can surface the right treatment recommendation, which means there is some amount of data capture that has to happen. In some circumstances, you know, we can pull some of that data in from the EHR.  But unfortunately, the reality is that a lot of that data is messy and it's sort of stuck in documents and unstructured places. And so it doesn't easily flow in, which means we rely on the provider to give us that information. And oftentimes they've already entered it other places. So what's more frustrating than entering data twice? But, you know, I do see a great opportunity here. And this is certainly where software companies are focused is with AI.  So, know, for, especially for this data aggregation, a lot of these AI tools can actually scan through the chart instead of relying on the physician to sort of manually skim through and aggregate and find all that pertinent information. That's what AI is really good at. And almost instantaneously, it can find the messy data that lives in those unstructured documents. And wouldn't it be nice if that was automatically populated within these applications so that really all we're asking of the clinician is to validate that that information is accurate. And then choose the treatment that cuts down on the number of clicks, it cuts down on frustration. You know, again, the physician will be the one that needs to make that decision. AI is not there to replace that, but it certainly has a great opportunity to reduce some of this manual documentation and the things that physicians find the most frustrating, especially as it relates to using these pathways tools.  Dr. John Sweetenham: One of the pretty common pushbacks that I heard during my time in a couple of institutions was, “Well, you know, I'm sitting here at the point of care with my patients and I already know what I want to do and how I'm going to treat that patient if it's not in the context of a clinical trial. So I don't need to go through, you know, X number of clicks to get me to where I know I'm going to be anyway.”  Does either of you have any thoughts about that? I think you've sort of partially answered it, but what do you think, Rebecca? Do you think that this is something that is more easily overcome-able, if that's even a word, than it was a few years back?  Rebecca Maniago: Yeah, I do. And I think this is where the customization comes into play. So while they may know what an appropriate treatment for their patient is, there are more options now than ever, which means at a local level, there may be multiple options that are clinically equivalent. And so when you think about things like payer pathways or drug margins as an organization, they have to drive some of that from within. But having the capability to do so can then start to sort of sell the value to the provider that, yes, you may know what you want to order for your patient, but would you consider something else if it was clinically equivalent, but it had other benefits to either the patient or the organization?  Dr. Larry Shulman: The other thing I would add to that, John, if I can jump in here is that the data is the data and the data shows us that guideline concordant care is not always prescribed to the US. And in fact, in some circumstances, the gaps between what should be prescribed and what is being prescribed are quite wide. So, you know, people feel like they're always doing the best job and making the best recommendations. And I think, you know, I think I am. But, you know, like many of my colleagues at academic cancer centers, I'm highly specialized. I only see patients with breast cancer. But many oncologists throughout the country are more generalists. They're seeing patients with multiple diseases. And it's harder for them to be completely on top of what the current recommendations are in any particular circumstance. Our diseases are complicated. They're getting more complicated all the time with molecular and genomic testing and subcategorizations of different cancers. So, I don't think that we can be too cocky about it, quite frankly. I think we ought to use technology that Rebecca describes for the tools and for AI to really help us. I think if we turn our backs on that, I think we're making a big mistake. You just got to look at the data. The data is pretty convincing.  Dr. John Sweetenham: You know ever since we started looking seriously at decision support through pathways a number of years ago, the word has always been around the payers role in this and the day will come where we are going to get reimbursed based on pathway and concordance and I'm not sure that that day has arrived. So I have a question for both of you in this regard actually. And the first of those is maybe I'll start with you for this part of it, Larry. Where do you think we are in that regard? And are you hearing more and more of payers starting to look at pathway compliance? And then on the other end of that, and maybe I'll ask Rebecca about this, is one of the other pushback issues that I used to experience from physicians I worked with was they may go through the pathways platform and come up with a treatment recommendation. The best example of this I can think might be that the recommendation might be a biosimilar. Let's just use that as an example. But the next stage in the process would be to find out whether the patient's insurance would actually cover that particular biosimilar, which opened up a whole new can of worms. So there are two kinds of payer aspects of that. Maybe Larry, I'll ask you to start off by talking about that kind of coverage issue. And then I'll ask Rebecca, if you have any thoughts about the flow the other way in terms of getting drugs approved and what we can do to help from an insurance perspective.  Dr. Larry Shulman: Sure, that's really an important point, John. Our current state of affairs with the payers and their attempt to be sure that we're providing responsible, guideline concordant care is the use of prior authorization processes, which are incredibly costly, both for the oncology practices and for the payers.  They have an army of nurses sitting at the phone talking to us in the oncology practices to decide whether they're going to pay for something. And frankly, generally, the payers will pay for things that are part of either the NCCN or ASCO or other professional organizations' guidelines. But you need to prove to them over the phone that in fact the patient qualifies for that.  We have actually had some experiments with some of the payers to prove that to them in different ways by auto transmission of data. And this would be a big savings for them and for us, it would take away some of the delays in therapy while we're waiting for prior authorizations to go through. And we shouldn't have to do this by phone.   The EHR and the pathway tools should aggregate the data, aggregate the potential treatment and be able to transmit those data to the payer. And if in fact it meets the appropriate criteria for guideline concordant care would be approved. Right now, it's a terrible, costly, timely manual process that they should be able to fix.  Dr. John Sweetenham: Thanks, Larry. And have you, you know, from a broader perspective, so not thinking necessarily about individual patients and specific issues around prior authorization, have you seen any movement among the payers to kind of get more aggressive about this and say, okay, you know, we are going to want to see your numbers, we want to know how many of your physicians are now using their pathways platform and so on. Are you seeing any word that that might be happening? Because certainly a few years back, that was the word on the street, as it were, that this day was coming.  Dr. Lawrence Shulman: And that's the proposal that we've made to several of our payers. Let us give you the aggregate data. If our guideline concordance is above a certain level, give us a gold card, give us a pass, and we won't need to do pre-authorizations. We've actually done that at my institution in radiology. Aggregate data gives individual physicians that pass if their guideline concordance was appropriate. I got to pass. So I don't need to go through those radiology pre-authorizations for my patients. And I think we can do the same thing with therapeutics. It's been a little bit more cumbersome to do it, and there's some detailed reasons why that is. But that's really what they want to know. And the payers want to know that patients are getting guideline concordant care, but they also realize it's not going be 100%. There are always a few outlier patients who require some variation from the guidelines. But if we get above 80% guideline concordant care, I think many of the payers would be happy to accept that as long as we continue to feed them the data. And that's the case in our radiology process with one of the payers is, you know, I get a gold card, but they continue to look at my data. And if I don't continue to perform well, they'll take that away.  Dr. John Sweetenham: Thanks, Larry. And Rebecca, just returning to you, this issue of prior authorization and facilitating life for the physician at the point of care in terms of knowing, you know, which specific treatment might be covered for a patient. Do you have any thoughts or maybe you could give us some insights on what software vendors are doing to facilitate that part of the process, the communication back to the payers to take some of that burden off the physician and the physician staff?  Rebecca Maniago: Yeah, absolutely. And this is a problem we've been trying to tackle for years. And it's not easy. We've tackled it in a couple ways. So first, we try to sort of link up to the payer portal where the information that was being attested to within the application could then be automatically sent. Because at the end of the day, the data points that are being collected to surface treatment recommendations ultimately are the same data points that the payer wants.  Unfortunately, there are a lot of data interoperability challenges within that space. So that was not something that was going to be sustainable. However, in current state, because as I mentioned, the customization is key for these products, focusing more on how can we allow practices to embed payer pathways within the application. So again, you kind of start with the backbone of your standard guidelines but then having the capability of adding in a payer pathway that will only show up as that preferred option for a patient who has that insurance, at least at the point of care, the provider sees what the insurer would then approve. So while it's not automatically assuring authorization, we are at least steering the decision in a direction where we think most likely this is going to be approved based upon the pathway that they have access to. So that sort of current state, I agree. We've been talking about this idea of gold carding for years.  Presumably the data is there today, right? Like we are able to capture structured data with every order placed to recognize concordance to Larry's point. All those reports are available to provide to payers. I just haven't seen a lot of practices have a lot of success when they tackle it on their own from that direction.  Dr. John Sweetenham: Right, thanks. Larry, you and I were at the NCCN annual meeting recently and I know that you've been quite heavily involved in the policy program and in the policy forums and so on at NCCN. Are you able to share anything from this year's meeting in terms of care pathways implementation and what you think might happen next in that regard?  Dr. Larry Shulman: NCCN, in my own opinion, has really led the way in defining what guideline concordant care is through their guidelines, which are very extensive, covering basically every cancer and every situation with every cancer. And it's really an astounding amount of amazing work that all of us use and the payers largely use as well. But they've increasingly understood that there's a gap between their guidelines and the implementation of their guidelines. And they are working on some things. They are working on the digitalization of their guidelines to make them more accessible, but also thinking about ways that they may, in fact, fit into the work processes that all of us have when we go to clinic.  They're acutely aware that the country is not where it needs to be in regard to a translation, if you will, of their guidelines in the practice. And I think we're all thinking really hard about whether there are things that we can team up to do, if you will, to try to close those gaps.  Dr. John Sweetenham: Great, thank you. Just switching gears a little bit back to you, if I can, Rebecca. I think you've said a little bit about this already. What do you think are the next steps that we need to take to more effectively implement these tools in the clinic? I think we've discussed a little bit some of the roadblocks to that. But where do you think we need to go next in terms of getting better use of these pathways?  Rebecca Maniago: Yeah, I will say one thing that we haven't really touched on is the pharmacy team. So the biggest blocker that I see is actually the pre-implementation. So there's a lot of focus on how do we get physicians to use this? How do we increase adoption? But often the first barrier is the regimen library. So no matter what the pathways platform is, the backbone of it will be those regimens. And so, really helping organizations and we partner with pharmacies, they're doing all the backend configuration. And so how can we make that piece of the technology easier for them to implement because that's really the lead up and there's a ton of cleanup and maintenance. You know, as a pharmacist, I empathize, but really that's where it all begins. And so I think, you know, continuing to focus on not only the front end user and the physician, but everybody that's going to be involved in order to make a pathway program successful needs to be, you know, at the table in the beginning, helping set up those processes and, and buying into the why this is important.  Dr. John Sweetenham: That's a great point.  Dr. Larry Shulman: So could I just jump in one quickly here, John? So pathways, as we've discussed, the tools are expensive. There is a person cost, as Rebecca is just describing, about customization and implementation. But there are very good data in the literature to show that when you follow pathways, care is less costly. Survival is better, which is obviously our primary goal, but also cost is less. And the payers can benefit from that. And the question is, can they figure out ways to use that to help to fund the purchase and maintenance of pathway products that will give their patients better care, but also less costly care? And so I think that is a potential solution. I've had that conversation with some payers as well. And it would be great to see that happen. I think that would be a huge step.  Rebecca Maniago: Yeah, we have some, if they're able to set it up in the right way and really optimize, you know, from the pharmacy perspective, we have practices who the application is more than, you know, paying for itself just by way of using it to the fullest potential that it has.  Dr. John Sweetenham: Yeah, that's a really great point. A couple of other more general questions. I'm going to start with you, Rebecca, and Larry ask you to respond as well. Are you hearing anything from patients around this issue? Are they aware or becoming more aware that pathways are being used in the clinic when they're seen by their physicians? And do they have a say, are there patient advocates involved in this part of the process? Rebecca, maybe you could start.  Rebecca Maniago: I haven't had as much exposure to that side of it. So, you know, I would love to hear what Larry thinks because most of my exposure is at the physician level, which of course they are the ones who are making the decision with the patient. So my assumption is that there is at least some level of understanding that there are options and that, you know, together let's decide on the best one for you. But again, I would love to hear what Larry has to say.  Dr. Larry Shulman: Yeah, so that's a really interesting question. I actually was discussing that at the cancer center last week, particularly around the utilization of AI in this process. And, you know, right now, as you know, if you submit a journal article or, you know, many other things, ask you whether you used AI to generate it. If in fact we use tools that include AI, we're not.  Are we obligated to tell the patient that you're making this recommendation together with computer assist, if you will, that helps you to make the recommendation you are making to them? Ultimately, I think it's the physician who's responsible for the choice, but should we disclose it? I have to tell you personally, I haven't thought about doing that. But I think it's a really, really good question is whether we should upfront tell the patients that we've had assistance in making the recommendations that we have.  Dr. John Sweetenham: Right, very interesting point. To close it out, one more question for both of you and again, it's the same one. Rebecca, to start with, we've all been, as I said right up front, talking and, you know, working on this issue for more than 10 years now. In 10 years from now, how would you like it to look and how do you think it might look?  Rebecca Maniago: Great question. I think we may get to where I would like to see it quicker than 10 years. I think AI provides a lot of opportunity and excitement. I'd love to turn a corner where physicians no longer see tools like this as a hindrance, rather they rely on them, they trust them, they help them get through their day. They continue to improve quality of care and reduce costs and patient burden. Obviously, that's the pipe dream, but I think we may get there before 10 years, given what I think AI is going to enable.  Dr. Larry Shulman: Yeah, I want to add to Rebecca's comments. One of the things that I worry about, and ASCO worries about a lot, is the oncology workforce, which is progressively strained in their attempts to care for all the cancer patients in the US. And for all of us who practice oncology, for many reasons, it's become more and more inefficient, whether it's use of the EHR, pre-authorization work, and so on.  And we really need to turn that around. We need to make practice not only better, which I think these tools can do, including AI, as Rebecca says, but make it much more efficient because that's going to allow us to both deliver more high-quality care to our patients, but also to care for more patients and have them benefit from our expertise and what we have to offer. So I think this is really an obligation on our part. I think it's an imperative that we move in this direction for both quality reasons and efficiency reasons.  Dr. John Sweetenham: Thanks, Larry. Well, I've really enjoyed the conversation today and I think, you know, it's been great to think about some of the challenges that we still have in this regard. But it's also great to hear what I'm sensing is quite a lot of optimism about how things may play out over the next few years. And it does sound as if there's a lot of hard work going on to bring us to a point where the clinical decision support tools are going to truly support what our oncologists are doing and no longer be seen as an obstruction. So, I want to thank you both for sharing your insights with us today on the ASCO Daily News Podcast.  Dr. Larry Shulman: Thank you so much, John.  Rebecca Maniago: Thank you so much.  Dr. John Sweetenham: And thank you to our listeners for your time today. If you value the insights that you hear on the ASCO Daily News Podcast, please take a moment to rate, review and subscribe wherever you get your podcasts.  Disclaimer:   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.   Find out more about today's speakers:  Dr. John Sweetenham  Dr. Lawrence Shulman  Rebecca Maniago  Follow ASCO on social media:  @ASCO on Twitter  @ASCO on Bluesky  ASCO on Facebook  ASCO on LinkedIn        Disclosures:  Dr. John Sweetenham:  No relationships to disclose    Dr. Lawrence Shulman:  Consulting or Advisory Role: Genetech     Rebecca Maniago:   No relationships to disclose.     

JCO PO author Dr. Timothy Showalter at Artera and University of Virginia shares insights into his JCO PO article, “Digital Pathology–Based Multimodal Artificial Intelligence Scores and Outcomes in a Randomized Phase III Trial in Men With Nonmetastatic Castration-Resistant Prostate Cancer” . Host Dr. Rafeh Naqash and Dr. Showalter discuss how multimodal AI as a prognostic marker in nonmetastatic castration-resistant prostate cancer may serve as a predictive biomarker with high-risk patients deriving the greatest benefit from treatment with apalutamide. TRANSCRIPT  Dr. Rafeh Naqash: Hello and welcome to JCO Precision Oncology Conversations where we'll bring you engaging conversations with authors of clinically relevant and highly significant JCO PO articles. I'm your host, Dr. Rafeh Naqash, podcast Editor for JCO Precision Oncology and assistant professor at the OU Health Stephenson Cancer Center at the University of Oklahoma. Today, we are excited to be joined by Dr. Timothy Showalter, Chief Medical Officer at Artera and professor of Radiation Oncology at the University of Virginia and author of the JCO Precision Oncology article entitled, “Digital Pathology Based Multimodal Artificial Intelligence Scores and Outcomes in a Randomized Phase 3 Trial in Men with Non-Metastatic Castration Resistant Prostate Cancer.” At the time of this recording, our guest's disclosures will be linked in the transcript. Dr. Showalter, it's a pleasure to have you here today. Dr. Timothy Showalter: It's a pleasure to be here. Thanks for having me. Dr. Rafeh Naqash: I think this is going to be a very interesting discussion, not just from a biomarker perspective, but also in terms of how technologies have evolved and how we are trying to stratify patients, trying to escalate or deescalate treatments based on biomarkers. And this article is a good example of that. One of the things I do want to highlight as part of this article is that Dr. Felix Feng is the first author for this article. Unfortunately, Dr. Felix Feng passed away in December of 2024. He was a luminary in this field of prostate cancer research. He was also the Chair of the NRG GU Committee as well as Board of Directors for RTOG Foundation and has mentored a lot of individuals from what I have heard. I didn't know Dr. Feng but heard a lot about him from my GU colleagues. It's a huge loss for the community, but it was an interesting surprise for me when I saw his name on this article as I was reviewing it. Could you briefly talk about Dr. Feng for a minute and how you knew him and how he's been an asset to the field? Dr. Timothy Showalter: Yeah. I'm always happy to talk about Felix whenever there's an opportunity. You know, I was fortunate to know Felix Feng for about 20 years as we met during our residency programs through a career development workshop that we both attended and stayed close ever since. And you know, he's someone who made an impact on hundreds of lives of cancer researchers and other radiation oncologists and physicians in addition to the cancer patients he helped, either through direct clinical care or through his innovation. For this project in particular, I first became involved soon after Felix had co-founded Artera, which is, you know the company that developed this. And because Felix was such a prolific researcher, he was actually involved in this and this research project from all different angles, both from the multimodal digital pathology tool to the trial itself and being part of moving the field forward in that way. It's really great to be able to sort of celebrate a great example of Felix's legacy, which is team science, and really moving the field forward in terms of translational projects based on clinical trials. So, it's a great opportunity to highlight some of his work and I'm really happy to talk about it with you. Dr. Rafeh Naqash: Thanks, Tim. Definitely a huge loss for the scientific community. And I did see a while back that there was an international symposium organized, showcasing his work for him to talk about his journey last year where more than 200, 250 people from around the globe actually attended that. That speaks volumes to the kind of impact he's had as an individual and impact he's had on the scientific side of things as well. Dr. Timothy Showalter: Yes. And we just had the second annual Feng Symposium the day before ASCO GU this year with, again, a great turnout and some great science highlighted, as well as a real focus on mentorship and team science and collaboration. Dr. Rafeh Naqash: Thank you so much for telling us all about that. Now going to what you guys published in JCO Precision Oncology, which is this article on using a biomarker approach to stratify non-metastatic prostate cancer using this artificial intelligence based H&E score. Could you tell us the background for what started off this project? And I see there is a clinical trial data set that you guys have used, but there's probably some background to how this score or how this technology came into being. So, could you superficially give us an idea of how that started? Dr. Timothy Showalter: Sure. So, the multimodal AI score was first published in a peer reviewed journal back in 2022 and the test was originally developed through a collaboration with the Radiation Therapy Oncology Group or Energy Oncology Prostate Cancer Research Team. The original publication describes development and validation of a risk stratification tool designed to predict distant metastasis and prostate cancer specific mortality for men with localized prostate cancer. And the first validation was in men who were treated with definitive radiation therapy. There have been subsequent publications in that context and there's a set of algorithms that have been validated in localized prostate cancer and there's a test that's listed on NCCN guidelines based on that technology. The genesis for this paper was really looking at extending that risk stratification tool that was developed in localized prostate cancer to see if it could one, validate in a non-metastatic castrate refractory prostate cancer population for patients enrolled on the SPARTAN trial. And two, whether there was a potential role for the test output in terms of predicting benefit from apalutamide for patients with non-metastatic prostate cancer. For patients who are enrolled on the SPARTAN study, almost 40% of them had H&E stain biopsy slide material available and were eligible to be included in this study. Dr. Rafeh Naqash: Going a step back to how prostate cancer, perhaps on the diagnostic side using the pathology images is different as you guys have Gleason scoring, which to the best of my knowledge is not necessarily something that most other tumor types use. Maybe Ki-67 is somewhat of a comparison in some of the neuroendocrine cancers where high Ki-67 correlates with aggressive biology for prognosis. And similarly high Gleason scores, as we know for some of the trainees, correlates with poor prognosis. So, was the idea behind this based on trying to stratify or sub-stratify Gleason scoring further, where you may not necessarily know what to do with the intermediate high Gleason score individual tumor tissues? Dr. Timothy Showalter: Well, yeah. I mean, Gleason score is a really powerful risk stratification tool. As you know, our clinical risk groupings are really anchored to Gleason scores as an important driver for that. And while that's a powerful tool, I think, you know, some of the original recognition for applying computer vision AI into this context is that there are likely many other features located in the morphology that can be used to build a prognostic model. Going back to the genesis of the discovery project for the multimodal AI model, I think Felix Feng would have described it as doing with digital pathology and computer vision AI what can otherwise be done with gene expression testing. You know, he would have approached it from a genomic perspective. That's what the idea was. So, it's along the line of what you're saying, which is to think about assigning a stronger Gleason score. But I think really more broadly, the motivation was to come up with an advanced complementary risk stratification tool that can be used in conjunction with clinical risk factors to help make better therapy recommendations potentially. So that was the motivation behind it. Dr. Rafeh Naqash: Sure. And one of the, I think, other important teaching points we try to think about, trainees of course, who are listening to this podcast, is trying to differentiate between prognostic and predictive scores. So, highlighting the results that you guys show in relation to the MMAI score, the digital pathology score, and outcomes as far as survival as well as outcomes in general, could you try to help the listeners understand the difference between the prognostic aspect of this test and the predictive aspect of this test? Dr. Timothy Showalter: So let me recap for the listeners what we found in the study and how it kind of fits into the prognostic and the predictive insights. So, one, you know, as I mentioned before, this is ultimately a model that was developed and validated for localized prostate cancer for risk stratification. So, first, the team looked at whether that same tool developed in localized prostate cancer serves as a prognostic tool in non-metastatic castrate-refractory prostate cancer. So, we applied the tool as it was previously developed and identified that about 2/3 of patients on the SPARTAN trial that had specimens available for analysis qualified as high risk and 1/3 of patients as either intermediate or low risk, which we called in the paper ‘non-high risk'. And we're able to show that the multimodal AI score, which ranges from 0 to 1, and risk group, was associated with metastasis free survival time to second progression or PFS 2 and overall survival. And so that shows that it performs as a prognostic tool in this setting. And this paper was the first validation of this tool in non-metastatic castrate-refractory prostate cancer. So, what that means to trainees is basically it helps you understand how aggressive that cancer is or better stratify the risk of progression over time. So that's the prognostic performance. Dr. Rafeh Naqash: Thank you for trying to explain that. It's always useful to get an example and understand the difference between prognostic and predictive. Now again, going back to the technology, which obviously is way more complicated than the four letter word MMAI, I per se haven't necessarily done research in this space, but I've collaborated with some individuals who've done digital pathology assessments, and one of the projects we worked on was TIL estimation and immune checkpoint related adverse events using some correlation and something that one of my collaborators had sent to me when we were working on this project as part of this H&E slide digitalization, you need color deconvolution, you need segmentation cell profiling. Superficially, is that something that was done as part of development of this MMAI score as well? Dr. Timothy Showalter You need a ground truth, right? So, you need to train your model to predict whatever the outcome is. You know, if you're designing an AI algorithm for Ki-67 or something I think you mentioned before, you would need to have a set of Ki-67 scores and train your models to create those scores. In this case, the clinical annotation for how we develop the multimodal AI algorithm is the clinical endpoints. So going back to how this tool was developed, the computer vision AI model is interpreting a set of features on the scan and what it's trying to do is identify high risk features and make a map that would ultimately predict clinical outcomes. So, it's a little bit different than the many digital pathology algorithms where the AI is being trained to predict a particular morphological finding. In this case, the ground truth that the model is trained to predict is the clinical outcome. Dr. Rafeh Naqash: Sure. And from what you explained earlier, obviously, tumors that had a high MMAI score were the ones that were benefiting the most from the ADT plus the applausive. Is this specific for this androgen receptor inhibitor or is it interchangeable with other inhibitors that are currently approved? Dr. Timothy Showalter: That's a great question and we don't know yet. So, as you're alluding to, we did find that the MMAI risk score was predictive for benefit from apalutamide and so it met the statistical definition of having a significant interaction p value so we can call it a predictive performance. And so far, we've only looked in this population for apalutamide. I think you're raising a really interesting point, which is the next question is, is this generalizable to other androgen receptor inhibitors? There will be future research looking at that, but I think it's too early to say. Just for summary, I think I mentioned before, there are about 40% of patients enrolled on the SPARTAN study had specimens available for inclusion in this analysis. So, the SPARTAN study did show in the entire clinical trial set that patients with non-metastatic castrate-refractory prostate cancer benefited from apalutamide. The current study did show that there seems to be a larger magnitude of benefit for those patients who are multimodal AI high risk scores. And I think that's very interesting research and suggests that there's some interaction there. But I certainly would want to emphasize that we have not shown that patients with intermediate or low risk don't benefit from apalutamide. I think we can say that the original study showed that that trial showed a benefit and that we've got this interesting story with multimodal AI as well. Dr. Rafeh Naqash: Sure. And I think from a similar comparison, ctDNA where ctDNA shows prognostic aspects, I treat people with lung cancer especially, and if you're ctDNA positive at a 3 to 4-month period, likely chances of you having a shorter disease-free interval is higher. Same thing I think for colorectal cancers. And now there are studies that are using ctDNA as an integral biomarker to stratify patients positive/negative and then decide on escalation/de-escalation of treatment. So, using a similar approach, is there something that is being done in the context of the H&E based stratification to de-intensify or intensify treatments based on this approach? Dr. Timothy Showalter: You're hitting right on the point in the most promising direction. You know, as we pointed out in the manuscript, one of the most exciting areas as a next step for this is to use a tool like this for stratification for prospective trials. The multimodal AI test is not being used currently in clinical trials of non-metastatic castrate-refractory prostate cancer, which is a disease setting for this paper. There are other trials that are in development or currently accruing where multimodal AI stratification approach is being taken, where you see among the high-risk scores, at least in the postoperative setting for a clinical trial that's open right now, high risk score patients are being randomized to basically a treatment intensification question. And then the multimodal AI low risk patients are being randomized to a de-intensification experimental arm where less androgen deprivation therapy is being given. So, I think it's a really promising area to see, and I think what has been shown is that this tool has been validated really across the disease continuum. And so, I think there are opportunities to do that in multiple clinical scenarios. Dr. Rafeh Naqash: Then moving on to the technological advancements, very fascinating how we've kind of evolved over the last 10 years perhaps, from DNA based biomarkers to RNA expression and now H&E. And when you look at cost savings, if you were to think of H&E as a simpler, easier methodology, perhaps, with the limitations that centers need to digitalize their slides, probably will have more cost savings. But in your experience, as you've tried to navigate this H&E aspect of trying to either develop the model or validate the model, what are some of the logistics that you've experienced can be a challenge? As we evolve in this biomarker space, how can centers try to tackle those challenges early on in terms of digitalizing data, whether it's simple data or slides for that matter? Dr. Timothy Showalter: I think there's two main areas to cover. One, I think that the push towards digitalization is going to be, I think, really driven by increasing availability and access to augmentative technologies like this multimodal AI technology where it's really adding some sort of a clinical insight beyond what is going to be generated through routine human diagnostic pathology. I think that when you can get these sorts of algorithms for patient care and have them so readily accessible with a fast turnaround time, I think that's really going to drive the field forward. Right now, in the United States, the latest data I've seen is that less than 10% of pathology labs have gone digital. So, we're still at an early stage in that. I hope that this test and similar ones are part of that push to go more digital. The other, I think, more interesting challenge that's a technical challenge but isn't about necessarily how you collect the data, but it certainly creates data volume challenges, is how do you deal with image robustness and sort of translating these tools into routine real-world settings. And as you can imagine, there's a lot of variation for staining protocols, intensity scanner variations, all these things that can affect the reliability of your test. And at least for this research group that I'm a part of that has developed this multimodal AI tool can tell you that the development is sophisticated, but very data and energy intensive in terms of how to deal with making a tool that can be consistent across a whole range of image parameters. And so that presents its own challenges for dealing with a large amount of compute time and AI cycles to make robust algorithms like that. And practically speaking, I think moving into other diseases and making this widely available, the size of data required and the amount of cloud compute time will be a real challenge. Dr. Rafeh Naqash: Thank you for summarizing. I can say that definitely, you know, this is maybe a small step in prostate cancer biomarker research, but perhaps a big step in the overall landscape of biomarker research in general. So definitely very interesting. Now, moving on to the next part of the discussion is more about you as a researcher, as an individual, your career path, if you can summarize that for us. And more interestingly, this intersection between being part of industry as well as academia for perhaps some of the listeners, trainees who might be thinking about what path they want to choose. Dr. Timothy Showalter: Sure. So, as you may know, I'm a professor at the University of Virginia and I climbed the academic ladder and had a full research grant program and thought I'd be in academia forever. And my story is that along the way, I kind of by accident ended up founding a medical device company that was called Advaray and that was related to NCI SBIR funding. And I found myself as a company founder and ultimately in that process, I started to learn about the opportunity to make an impact by being an innovator within the industry space. And that was really the starting point for me. About four years ago, soon after Felix Feng co-founded Artera, he called me and told me that he needed me to join the company. For those who were lucky to know Felix well, at that very moment, it was inevitable that I was going to join Artera and be a part of this. He was just so persuasive. So, I will say, you know, from my experience of being sort of in between the academic and industry area, it's been a really great opportunity for me to enter a space where there's another way of making an impact within cancer care. I've gotten to work with top notch collaborators, work on great science, and be part of a team that's growing a company that can make technology like this available. Dr. Rafeh Naqash: Thank you so much, Tim, for sharing some of those thoughts and insights. We really appreciate you discussing this very interesting work with us and also appreciate you submitting this to JCO Precision Oncology and hopefully we'll see more of this as this space evolves and maybe perhaps bigger more better validation studies in the context of this test. Thank you for listening to JCO Precision Oncology Conversations. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all ASCO shows at asco.org/podcast.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  

The International Psycho-Oncology Society (IPOS) deemed April 9th, 2025, the first-ever World Psycho-Oncology Day (WPOD). This day was meant to spread awareness of the importance of prioritizing psychosocial care for patients with all types of cancer as well as to honor Jimmie C. Holland, MD. Prior to WPOD, CancerNetwork® spoke with Cristiane Decat Bergerot, PhD, BS, MS, a psychologist and the head of supportive care at Grupo Oncoclinicas in Brazil, and a member of IPOS, about the importance of psychosocial care and the impact it has on patients with cancer. As stated by Bergerot and listed on the official IPOS website, the primary goals of WPOD are as follows: raise awareness, honor Jimmie Holland, engage stakeholders, promote action, and support fundraising efforts.1 These goals are geared towards paying homage to the history of psycho-oncology and pushing for a more advanced future. “We aim to empower patients, caregivers, and healthcare professionals, fostering a future where psychosocial support is an integral part of oncology worldwide,” Bergerot said.  Psycho-oncology has become more prevalent as a cancer care field since Jimmie C. Holland, MD, worked to help found it in the 1970s. Holland, a “pioneer” of psycho-oncology, was the first ever Chief of Psychiatry Services—a department that was the first of its kind anywhere in the world—at Memorial Sloan Kettering Cancer Center, and a founding member of IPOS.  Bergerot stated that, in her work, she sees that patients who receive psychological support exhibit improved pain management and quality of life. Trials now focus more on end points such as quality of life and patient-reported outcomes, and guidelines have emerged to create standards of care. The National Comprehensive Cancer Network and the American Society of Clinical Oncology each offer guidelines that detail how to manage patient distress as they progress through cancer therapy.2,3 Distress screenings and earlier recommendations for palliative care have also become more standard in treatment.  As for the future, Bergerot highlighted that psychosocial care needs to be more integrated into care as a necessary, rather than optional, component. New developments around the world, however, have created a landscape where telehealth and new research demonstrate the potential to help psycho-oncology grow rapidly.  References 1.        World Psycho-Oncology Day (WPOD). IPOS. Accessed April 2, 2025. https://tinyurl.com/43c9rr2c 2.        Distress during cancer care. NCCN. 2024. Accessed April 2, 2025. https://tinyurl.com/ycxxvnmt 3.        Andersen BL, Lacchetti C, Ashing K, et al. Management of anxiety and depression in adult survivors of cancer: ASCO guideline update. J Clin Oncol. 2023;41(18):3426-3453. doi:10.1200/JCO.23.00293

Learn how your treatment plan is decided and terms you may seeWe continue our series to help you understand cancer and its treatment. This week we focus on surgery, the oldest form of cancer treatment. Learn about surgery timing, types of cancer surgery, and how NCCN evidence-based guidelines provide a standard treatment path no matter where you are.In this Episode:02:58 - Wisconsin-Cheese, UFOs, and Booyah Stew04:52 - Anna Quindlen: Get a Life Where You Are Generous"08:06 - Medical Specialists Involved in Cancer Care08:52 - Treatment Decisions, Tumor Board and NCCN Guidelines12:03 - Adjuvant and Neoadjuvant Therapy13:13 - Surgery Timing, Reasons and Types18:00 - Discussion - NCCN and Role of Research24:34 - Reeves Keyworth:“On Loved Ones Telling the Dying to ‘Let Go”23:54 - OutroSurgery, radiation therapy, and chemotherapy alone or in combination are the most-common methods used to treat cancer. Specific treatment varies depending on the kind of cancer, the extent of the disease, its rate of progression, and the condition of the person. Surgery alone may not result in a cure and often chemotherapy and/or radiation are needed after surgery. Learn all about surgery and the guidelines your doctor will be following for your treatment.Support the showGet show notes and resources at our website: every1dies.org. Facebook | Instagram | YouTube | mail@every1dies.org

Dr. Vamsi Velcheti and Dr. Charu Aggarwal discuss the evolution of ctDNA as a critical tool in precision oncology and its implications for lung cancer management, including its potential role in the early-stage setting. TRANSCRIPT Dr. Vamsi Velcheti: Hello. I am Dr. Vamsi Velcheti, your guest host for the ASCO Daily News Podcast today. I am a professor of medicine and director of thoracic medical oncology at the Perlmutter Cancer Center at NYU Langone Health.  The management of small cell lung cancer has rapidly evolved over the past few decades, and today, molecular testing and biomarker testing for lung cancer are absolutely critical in terms of designing treatment options for our patients with metastatic non-small cell lung cancer. Today, I'm delighted to be joined by Dr. Charu Aggarwal for a discussion on ctDNA (circulating tumor DNA) and the role of ctDNA in lung cancer management. Dr. Aggarwal is the Leslye Heisler Professor of Lung Cancer Excellence and section chief of thoracic and head and neck oncology at University of Pennsylvania Abramson Cancer Center.  You'll find our full disclosures in the transcript of that episode.  Dr. Agrawal, it's great to have you on the podcast today. Thank you for being here. Dr. Charu Aggarwal: Thank you for having me. Dr. Vamsi Velcheti: Let's start off with setting the stage for ctDNA technology. These technologies have rapidly evolved from experimental conceptual stage to essential clinical tools for day-to-day clinical practice. Could you briefly discuss how recent advancements in ctDNA technologies are shaping our approach to precision medicine, especially in lung cancer? Dr. Charu Aggarwal: Absolutely. And you know, I think we need to just level set a little bit. What exactly is circulating tumor DNA? This is a way to assess exactly that. Every tumor sheds little pieces of tumor-derived DNA into the bloodstream, and this occurs in a variety of solid tumors. But now we have the technology to be able to derive this DNA that's actually being shed from the tumor into the bloodstream, these minute fragments of DNA, take them out, amplify them and sequence them with a variety of different mechanisms. They can be DNA sequencing alone, they can be DNA and RNA sequencing, they can be whole transcriptome sequencing. The technology, as you rightly pointed out, Dr. Velcheti, has significantly improved from just being able to look at circulating tumor DNA to now being able to amplify it, sequence it, and use it to offer personalized therapy. I think lung cancer is definitely the poster child for such an approach as we have a lot of data that has shown clinical utility and validity of being able to use circulating tumor DNA next-generation gene sequencing to guide therapy. Dr. Vamsi Velcheti: There have been so many technological leaps. It's really impressive how far we've come to advance these sequencing platforms. Recent advances with AI and machine learning are also playing important roles in interpreting ctDNA data. How are these computational advances really enhancing clinical decision-making in day-to-day clinical practice? Dr. Charu Aggarwal: I think while we have firmly established the role of ctDNA in the management of patients with metastatic lung cancer, some of the approaches that you talked about are still experimental. So let me backtrack a little bit and set the stage for how we use ctDNA in clinical practice right now. I think most patients, when they come in with a new diagnosis of stage IV lung cancer, we want to test for biomarkers. And this should actually be the established standard. Now included in the NCCN guidelines and actually also international guidelines, is to consider using blood-based testing or plasma-based testing to look for biomarkers, not just tissue-based testing which had been our historical standard, but to use these plasma guided approaches to identify the seven to nine biomarkers that may be truly implicated in either first- or second-line therapy that are called as your immediately actionable mutations.  What you're talking about is AI computational methods. I think there's a lot of excitement about how we can use genomic signatures that are derived from either tissue or ctDNA-based biomarker testing, combine it with radiomic features, combine it with histologic features, look at H & E patterns, use AI algorithmic learning to be able to actually predict recurrence scores, or can we actually come up with predictive signatures that may be extremely helpful?  So, I think some of the techniques and technologies that you're talking about are incoming. They are provocative. I think they're very exciting, but very early. Dr. Vamsi Velcheti: I think it's really amazing how many advances we have with these platforms. You know, the challenge really is the significant gap in terms of uptake of molecular testing. Even today, in 2025, there are significant gaps in terms of all metastatic lung cancer patients being tested for all biomarkers.  So, why do you think there's such a challenge in testing patients with lung cancer? In most academic practices, we try to achieve 100% testing for all our patients, but we know from recent studies that that's not the case across the country. What do you think the gaps are? Dr. Charu Aggarwal: Biomarker testing is so essential, like you pointed out, for us to be able to guide the right therapy for our patients. And we see this in our practice every day as you and I see patients with lung cancer, that a large proportion of our patients either don't get tested or they start therapy before their test results come back. So, I think this is a real problem.  However, to add some optimism to this problem, I do think that we are making a move in the right direction. So, four or five years ago, there was a lot of data being presented at national meetings, including ones from the American Society of Clinical Oncology, where we saw that, nationally, the rates of biomarker testing were probably in the rate of 40 to 50%. However, now with the availability of both tissue and plasma, I do think that the rates of biomarker testing are increasing. And if you were to survey a sample or even perform retrospective data research, I believe that the number is closer to 70% of all patients with metastatic non-small cell lung cancer.  And you know, you asked why is it not 100%? I think there are many reasons. I think the number one reason is tissue availability. Many times, the biopsies are small, or the tumor is very necrotic. So, either the tissue quantity itself is small, or the tissue quantity is insufficient to perform gene sequencing. And that's exactly where plasma comes in. When you don't have tissue availability, we have shown, as have others, that you can use plasma effectively to increase the proportion of patients who are not only tested but also receive the right therapy. I think there are also other barriers, including inertia. You know, I think this is both patient and physician inertia, where patients want to get started quickly, they don't want to wait. Physicians are very busy and sometimes want to be able to deliver treatment as soon as possible. We have seen there are some institutional barriers. Not every institution has in-house gene sequencing testing. So how do you really operationalize, send out these tests in a fast, efficient manner so that you get results back? Is it a pathologist who sends out the test? Is it the medical oncologist? Is it the pulmonologist or the interventionalist? I think there is this need to develop reflex testing mechanisms which some institutions do really well and some don't. And then finally, there are financial implications as well. How do we do this in a most cost-efficient fashion?  So there are many barriers, but I'm happy to say that we are making a move in the right direction as we are understanding that it's important to do it, it's easy to do it maybe with a value add of plasma, and finally, as you said, you know, as these technologies become more available, they're actually getting more cost-effective. Dr. Vamsi Velcheti: Dr. Aggarwal, you've been at the cutting edge of these advanced platforms and testing. So, what do you do in UPenn? How do you handle all these barriers and what is your workflow for patients in University of Pennsylvania? Dr. Charu Aggarwal: One of the things that I mentioned to you was there may be institutional barriers when it comes to gene sequencing. So, we actually, several years ago now, instituted a very robust reflex testing paradigm where almost all of our patients, regardless of stage, with a non-squamous non-small cell lung cancer diagnosis, would automatically be reflexively sent to our molecular pathology lab where they would get gene sequencing both for the DNA as well as with an RNA fusion-based platform. And the reason we did this was because we wanted to expedite and reduce the turnaround time. We also wanted to ensure that we were not just doing DNA testing, which I think is really important for our listeners here. There are many fusions as well as certain skipping mutations like MET exon 14 that may be missed on DNA testing alone. So, it's really incredibly important to run both DNA and RNA samples.  So, we do this routinely, and based on our research and others, what we also do routinely is that we send concurrent tissue and liquid biopsies or plasma MGS testing upon initial diagnosis. For example, if a patient comes in with a diagnosis of stage IV non-small cell lung cancer, their tissue might already be at my molecular pathology lab based on the reflex mechanism that I just described to you. But upon their initial meeting with me, we will send off plasma. And I will tell you this, that Penn is not just one institution, right? We have a large network of sites. And as part of my research, one of the things that we wanted to do was implement wide scale means to improve biomarker testing. And we have done this with the use of technology like you mentioned, Dr. Velcheti: How can we actually use AI? How can we leverage our electronic medical record to identify these patients? So, we have a nudge-based mechanism which actually facilitates the pending of orders for biomarker testing for patients with new diagnosis of metastatic non-small cell lung cancer. And we are looking at our rates of biomarker testing but also rates of completion of biomarker testing before first-line therapy started. So many of our participating sites are clusters for our randomized control trial to increase molecular testing. And I'm really excited about the fact that we're able to implement it not just at our main satellite, downtown Penn Hospital, but also across our community. Dr. Vamsi Velcheti: I think that's great. Thank you so much for those insights, Dr. Aggarwal. I think it's so important because having the best technology is just not enough. I think implementation science is actually a real thing. And I think we need to all learn from each other, advance these things.  So, I want to ask you about the new emerging paradigm in terms of using ctDNA. Of course, in the metastatic setting, we've been using ctDNA for molecular profiling for a while now. But the recent data around monitoring early-stage disease, especially post-operative monitoring, is an exciting area. There are a lot of opportunities there. Could you please talk us through the emerging data in lung cancer and how do we incorporate ctDNA-based monitoring MRD or should we even do that right now? Is the data ripe enough for us to kind of deploy this in a clinical setting? Dr. Charu Aggarwal: I think using ctDNA in the early-stage setting is our next frontier in lung cancer. I think naturally we have been able to successfully deploy this in the stage 4 setting. It made a meaningful difference in the lives of our patients, and we are a little bit behind the A ball in terms of how MRD is used in lung cancer. Because, you know, colorectal cancer has already done large-randomized trials based on ctDNA and MRD. It's routinely used in hematological malignancy. So, it makes sense that we should start to use it.  However, when I say this, I say this with excitement, but also a little bit of gentle caution saying that we actually don't quite have the prospective randomized data just yet on how to deploy. Yes, intuitively we would say that if you detect ctDNA and MRD, that patient is at higher risk. So, we identify that, but we actually don't know what to do with the second part of that information once you identify a patient with high risk. Are there other techniques that we can then come in with or other drugs that we can come in with to modify that risk? And that's the thing that I think we don't have right now. The other thing that we don't have right now is the timing of the assay, when to use it. Is it to be tested in the pre-op setting? Is the post-op test the best timing, or is it monitoring and dynamics of ctDNA that are most important? And the third thing I will say in terms of precautionary cause is that we don't know which test just yet. There are actually a few commercially available tests out in the market right now. We know about them and I'm sure our community colleagues know about them. Some of them even have Medicare approval. However, many of these tests are currently tissue informed. We don't have tissue uninformed tests. And what does that mean? Tissue uninformed means that you actually take a piece of tumor tissue, you sequence that tumor and based on the gene profile of that tumor, you actually design a panel that can then be used to track the mutations in the blood-based pack. This requires, as the name implies, a tumor. So can this be used in the pre-op setting is a large question. Because coming back to the idea of tissue availability, you and I both know that when we get FNAS and we use it for PDL-1 testing and we use it for gene sequencing, there often isn't enough tissue left for us to then either do whole genome sequencing or even whole transcriptome sequencing, which may be required to build some of these assays.  I think the future lies in this idea of tumor uninformed assays because if we could go to a blood only or a plasma only approach using novel signatures like proteomics or methylation, I think that's where the future is. But we're still a little bit early in the discovery stages of those, as well as to come are the validation stages so that we can be confident that these blood-only assays may actually give us an answer.  So, with those three cautionary notes, I would say that optimism is still very high. I think ctDNA MRD is the right place to think about. We need to do this for our patients to better identify high-risk patients and to think about means to escalate treatment for them. Dr. Vamsi Velcheti: Yeah, I completely agree, and I think with all the changes and evolution of treatments in the management of early-stage lung cancer now with neoadjuvant and adjuvant, there's really a need for an escalation and de-escalation of therapies post-operatively. And I think it's a huge opportunity. I think we all could learn from our colorectal colleagues. I think they've done a really good job at actually doing prospective trials in this setting. I think we're kind of a little behind here.  Dr. Charu Aggarwal: I think in the metastatic setting there are ongoing trials to look at this exact question. How do you choose an appropriate first-line therapy, a monitor ctDNA at the six-week trial? It's being evaluated in a trial called the “Shedders” trial, where if patients are still ctDNA positive at six weeks, then you can escalate treatment because they haven't “cleared” their ctDNA. There has been a lot of research that has shown that lack of ctDNA clearance in the metastatic setting may be a poor prognostic factor. We and others have shown that if you do clear your ctDNA or if you have a reduction in ctDNA load overall, that that is directly related to both an improved progression-free survival and overall survival. This has been shown with both tissue informed and uninformed assays. So I think it's very clear that yes, you can track it. I think the question is: Can you apply that data to the early-stage setting? And that's an open research question. A lot of groups are looking at that and I think it's completely reasonable, especially to determine duration of therapy, to determine optimal timing, optimal timing of scans even. And I think these are just such interesting questions that will be answered in the future. Dr. Vamsi Velcheti: And also like a kind of early detection of resistance patterns that might inform early initiation of combination strategies. And I think it's a lot of opportunities I think yet to be explored. A lot of exciting things to come and I'm sure we'll kind of see more and more data in the next few years.  Dr. Aggarwal, thank you so much for sharing your fantastic insights today on the ASCO Daily News Podcast. It's been a pleasure to have you on the podcast today. Hope to see you at ASCO. Dr. Charu Aggarwal: Thank you so much. This was great and I remain so excited by all of the possibilities to improve outcomes for our patients. Dr. Vamsi Velcheti: Thank you to all the listeners for your time today. If you value the insights that you hear from the ASCO Daily News Podcast, please take a moment to rate, review and subscribe wherever you get your podcast. Thank you so much. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement. Follow today's speakers:  Dr. Vamsidhar Velcheti  @VamsiVelcheti  @vamsivelcheti.bsky.social Dr. Charu Aggarwal @CharuAggarwalMD   Follow ASCO on social media:  @ASCO on X (formerly Twitter)  ASCO on Bluesky ASCO on Facebook  ASCO on LinkedIn    Disclosures: Dr. Vamsidhar Velcheti:  Honoraria: Glavanize Therapeutics Consulting or Advisory Role: Bristol-Myers Squibb, Merck, AstraZeneca/MedImmune, GSK, Amgen, Taiho Oncology, Novocure, Takeda, Janssen Oncology, Picture Health, Regeneron Research Funding (Inst.): Genentech, Trovagene, Eisai, OncoPlex Diagnostics, Alkermes, NantOmics, Genoptix, Altor BioScience, Merck, Bristol-Myers Squibb, Atreca, Heat Biologics, Leap Therapeutics, RSIP Vision, GlaxoSmithKline  Dr. Charu Aggarwal: Consulting or Advisory Role: AstraZeneca, Daiichi Sankyo/AstraZeneca, Regeneron/Sanofi, Pfizer, Boehringer Ingelheim, Takeda, Arcus Biosciences, Gilead Sciences, Novocure, Abbvie Speakers' Bureau: AstraZeneca (an immediate family member) Research Funding (Inst): Merck Sharp & Dohme, AstraZeneca/MedImmune, Daiichi Sankyo/AstraZeneca, Lilly@Loxo, Candel Therapeutics  

This episode of Cancer Registry World features Dr. Wui-Jin Koh, Senior Vice President and Chief Medical Officer of the National Comprehensive Cancer Network (NCCN). Dr. Koh explores the vital role of cancer registry data in shaping treatment guidelines and how data-driven guidelines contribute to advancements in cancer management. Tune in to gain valuable insights from this important discussion.

În cadrul ediției de pe 18 martie a emisiunii Știința360 de pe Radio România Cultural, Dr. Marius Geantă, Președintele Centrului pentru Inovație în Medicină, a comentat ultimele noutăți din domeniul sănătății. Un studiu publicat în Nature Medicine a raportat remisia pe termen lung la pacienții cu neuroblastom tratați cu terapie CAR-T direcționată către GD2. Unii pacienți au rămas fără semne de cancer timp de peste un deceniu, marcând un progres semnificativ în tratamentul tumorilor solide. Această cercetare oferă noi perspective asupra potențialului terapiei CAR-T dincolo de cancerele hematologice, aplicațiilor lor extinzându-se la tumori solide precum neuroblastomul.Terapia cu celule T cu receptor antigenic chimeric (CAR-T) este o metodă inovatoare de tratare a cancerului. Aceasta implică extragerea celulelor T ale pacientului—o componentă esențială a sistemului imunitar—modificarea lor genetică pentru a exprima receptori speciali (CAR) care vizează celulele canceroase și apoi, reinfuzarea CAR-T în organism. Aceste celule T modificate recunosc proteinele specifice de pe celulele canceroase și le atacă.Neuroblastomul este un cancer rar care afectează în principal copiii sub cinci ani. Acesta își are originea în celulele nervoase imature și este cunoscut pentru rata ridicată de recidivă, ceea ce face tratamentul deosebit de dificil. Între 2004 și 2009, cercetătorii au desfășurat un studiu clinic de fază I pentru a testa o terapie CAR-T inovatoare direcționată către GD2, o proteină supraexprimată în celulele de neuroblastom. Această terapie a utilizat două tipuri de celule T modificate: celule T activate (ATC) și celule T specifice virusului Epstein-Barr (VST), ambele concepute pentru a recunoaște și distruge celulele tumorale.Mai multe detalii despre subiectele discutate - ▶ Noi variante genetice asociate fibrilației atriale, descrise în cel mai amplu studiu de până acum▶ Noile recomandări NCCN pentru testarea ADN-ului tumoral circulant ca marker de prognostic pentru cancerul de colon, rect și carcinomul cu celule Merkel▶ Testul MyProstateScore 2.0, validat clinic pentru depistarea cancerului agresiv de prostată din probe de urină▶ Remisiune de 15 ani la pacienții cu neuroblastom tratați cu terapia CAR-T anti-GD2Ascultă emisiunea pe Radio România Cultural.

Dr. Shaalan Beg and Dr. David Wang discuss key abstracts in GI cancers from the 2025 ASCO Gastrointestinal Cancers Symposium, including major advances in CRC, neoadjuvant approaches in esophageal cancer, and innovative studies on ctDNA. TRANSCRIPT Dr. Shaalan Beg: Hello and welcome to the ASCO Daily News Podcast. I'm Dr. Shaalan Beg. I'm a medical oncologist and an adjunct associate professor at UT Southwestern Medical Center in Dallas. Today, we're bringing you some key highlights from the 2025 ASCO Gastrointestinal Cancers Symposium, and I'm delighted to be joined by the chair of GI25, Dr. David Wang. Dr. Wang is a GI medical oncologist at the University of Michigan. Our full disclosures are available in the transcript of this episode.  Dr. Wang, thanks for coming on the podcast today. Dr. David Wang: Well, thank you. It's a pleasure to be here. Dr. Shaalan Beg: GI25 featured major therapeutic advances across the spectrum of GI malignancies, and it was exciting to hear about innovations and novel approaches that are shaping the future of our field. Before we start talking about specific abstracts, could you share some of your key highlights from the meeting? Dr. David Wang: Sure. Our theme this year was “Breaking Boundaries to Enhance Patient Centered Care.” Past years' themes have focused more on precision oncology, but we wanted to broaden our focus on patients and to be more holistic, which kind of led us into some of the Intersection [sessions] that we had. Each day started with a different Intersection. The first one was “Emerging Therapies in GI Cancers”, where invited speakers talked about bispecific antibody drug conjugates, theranostics, CAR T and other cell-based therapies. The second day was on “Personalized Risk Assessment for GI Cancers,” and this included looking at polygenic risk scores for colorectal cancer, microRNAs and liquid biopsies such as exosomes and pancreatic cancer and non-endoscopic screening modalities in esophageal cancer. And on our final day, we wanted to talk about “Integrative Oncology and Integrative Medicine,” looking at evidence-based uses of acupuncture and supplements in patients who are receiving treatment for cancer, mindfulness-based practices and exercise. And of course, we had a fantastic keynote talk by Dr. Pamela Kunz from the Yale School of Medicine titled, “Disrupting Gastrointestinal Oncology: Shattering Barriers with Inclusive Science.” She highlighted the intersection of science, patient care, and health and gender equity. And I would encourage your podcast listeners to access the lecture in ASCO's Meeting Library if they haven't yet had a chance to hear Dr. Kunz's wonderful lecture.  We were really happy this year because the attendance hit a new record. We had over 5,000 people attend either in person or virtually from their home or office, and we had almost 1,000 abstracts submitted to the meeting, so these were either record or near record numbers. We offered a lot of different networking opportunities throughout the meeting, and attending found these to be incredibly rewarding and important and this will continue to be an area of emphasis in future meetings. Dr. Shaalan Beg: Let's take a deeper dive into the exciting studies presented at GI25. The late breaking abstract LBA143 was CheckMate-8HW. This was the first results of NIVO + IPI versus NIVO monotherapy for MSI-high metastatic colorectal cancer. What are your thoughts about this study? Dr. David Wang: Yeah, so we know that colorectal cancer patients with MSI-high tumors don't necessarily respond well to chemotherapy. And we were fortunate because last year CheckMate-8HW actually looked at two different arms – so this was NIVO + IPI compared to standard of care chemotherapy and showed its very significant improvement in median progression-free survival. And that was actually published in the New England Journal of Medicine back in November of 2024. This year's presentation actually focused now on NIVO + IPI versus NIVO monotherapy. And as you know IPI+NIVO can be quite toxic. So this was an important analysis to be done. So we know that NIVO is definitely more easily tolerated. So what was interesting was that the 2-year and 3-year progression-free survival not surprisingly favored IPI+NIVO and this was statistically significant. And the overall response rate was also better with IPI+NIVO versus NIVO alone. I know we're always concerned about toxicities and there were higher grade 3 and 4 toxicity incidences in the combination arm versus the monotherapy arm, but overall, only about 28 additional events in several hundred patients treated. So I think that's well-tolerated. Our discussant Dr. Wells Messersmith actually said that, with this new data, he would consider doing combination immunotherapy in any patient that presented in the front line with MSI-high or deficient mismatch repair colorectal cancer that was metastatic. Dr. Shaalan Beg: One of the focuses for directing first-line therapy for colorectal cancer has been right and left sided colon cancer because we know these are two different cancers with their own unique molecular subtypes. We heard on Abstract 17, the DEEPER trial, the final analysis of modified FOLFOXIRI plus cetuximab versus bevacizumab for RAS wild-type and left sided metastatic colorectal cancer. How do you summarize the findings of this study and what should our readers be aware of? Dr. David Wang: Interestingly, this was a phase 2 study and the emphasis of the abstract was actually a subgroup analysis of those patients with RAS wild-type and BRAF wild-type as well as left sided cancers. So, I think the entire study enrolled 359 patients, but the analysis that was discussed at the meeting really focused on 178 patients that fit that characteristic. Very similar to what we've seen in prior studies, left-sided tumors have better response to cetuximab versus bevacizumab. And if you flip it so that you now are looking at right sided tumors, targeting EGFR is actually detrimental. The depth of response was better with cetuximab in these left sided RAS and BRAF mutant tumors. And so the lead author actually suggested that this could be a new first-line standard of care. And the question is, is there a benefit of doing this triple agent regimen with modified FOLFIRINOX? We know there's a lot more toxicity with that. Not clear that there's a benefit for that over FOLFOX, maybe in younger patients that could tolerate it. When our discussant, again Dr. Wells Messersmith, spoke about this, he said that, in his practice he would, again, favor cetuximab over bevacizumab in combination with chemo, these left-sided RAS and BRAF wild-type tumors, but that he would actually prefer a doublet versus a triplet chemo regimen, and that is consistent with the current NCCN guidelines. Dr. Shaalan Beg: Another area where colorectal cancer has been a wonderful model to study new technology has been in the area of circulating tumor DNA (ctDNA). And the BESPOKE CRC trial is looking to see if ctDNA can inform adjuvant treatment decisions for stage II and III colorectal cancer. And in Abstract 15, we heard final results of the BESPOKE CRC sub-cohort. What were the findings there? Dr. David Wang: BESPOKE CRC is another one of these important ctDNA studies. It was an observational study, not a randomized trial, but it did provide a lot of different insights to us. We know that there were over 1,700 patients enrolled, and so it was reported that this is the largest ctDNA study in colorectal cancer performed in the United States. And they were able to analyze over 1,100 patients.  Some of the key findings were that postoperative adjuvant therapy management decisions actually changed in 1 out of 6 patients, so that's pretty significant. In terms of surveillance, we know that patients who have ctDNA positivity, this is prognostic of recurrence. In terms of patients who have positive ctDNA post-surgery, it looked like, at least in this observational study, the majority of patients who received any benefit were those who had positive ctDNA. So adjuvant therapy, even in stage II and stage III patients seemed to only benefit those patients who have positive ctDNA. I think that does raise the question, and this also was brought up in the discussion, which is “Can we de-escalate adjuvant therapy in terms of patients who are ctDNA-negative post-op?” And Dr. Richard Kim from Moffitt felt that we are not yet there. Obviously, we need randomized control trials where we are taking ctDNA results and then randomizing patients to receive adjuvant or non-adjuvant to really know the difference.  Other questions that come up with use of ctDNA include: What do you do with these patients who turn positive? This study for BESPOKE actually followed patients out to two years after surgery. So what you do with a positive ctDNA result wasn't really clear. It seems to suggest that once you turn positive, patients go on to more intensive surveillance. You know, again as an observation, patients who did turn positive were able to go to metastasis-directed therapy much more quickly. And again, this was supposedly to improve their curative intent therapy. And I think the other question that has been brought up all the time is, is this really cost effective? Patients want to know, and we want to give patients that information, but I think we're still stuck with what to do with a positive ctDNA level in a patient that's on surveillance because no randomized control studies have actually suggested that we need to start systemic therapy right away. Dr. Shaalan Beg: Yeah. And I guess in terms of practice informing or practice changing, these results may not give us a clear answer. But because a lot of patients are asking for these tests, it does give us some real world experiences on what to expect in terms of conversion of these positive into negative and the outcome so we can have a shared decision making with our patients in the clinic and then come up with a determination on whether ctDNA for molecular residual disease is something which would be worthwhile for the care of our patient. But more to come, I guess, in coming years to answer different problems around this challenge. Dr. David Wang: Yes, I agree. Dr. Shaalan Beg: The BREAKWATER trial looked at the use of encorafenib, cetuximab and chemotherapy for BRAF V600E-mutant metastatic colorectal cancer. We've covered this combination for a second- third-line treatment in metastatic colorectal cancer previously. Abstract 16 from GI25 was evaluating the use of this regimen in the first-line space. Everyone was looking forward to these results, and what did the investigators present? Dr. David Wang: I think this is, as you mentioned, a nice follow up to later lines of therapy where Dr. Kopetz from MD Anderson pioneered use of encorafenib, cetuximab and binimetinib in the BEACON trial. Everybody was kind of curious what would happen now if you use encorafenib plus cetuximab plus chemotherapy in the first-line setting. And so this is an interim analysis that was pre-planned in the phase 3 open label BREAKWATER trial. And even though there were three arms, and so the three arms were encorafenib plus cetuximab, encorafenib plus cetuximab plus FOLFOX, or standard of care chemo, only two arms were presented in the abstract. So basically looking at encorafenib plus cetuximab and FOLFOX-6 versus standard of care therapy, and the overall response rate was statistically significant with a 60.9% overall response rate encorafenib plus cetuximab plus chemo arm versus standard of care chemo was only 40%. The interim overall survival also was different. It was 92% versus 87% at 6 months and 79% versus 66% at 12 months, again favoring the chemotherapy plus encorafenib plus cetuximab. In terms of the statistics, the p was 0.0004. However, the pre-plan analysis required the p-value to be 1x10 to the -8. And so even though this looks really good, it hasn't quite met its pre-specified significance level. The good thing is that this is only interim analysis and the study is ongoing with future analysis planned.  So the real question is: Does it matter when we actually use this regimen? We know that the regimen's approved in the second third-line setting. What about in the first line? And there was some preclinical data that the discussant reviewed that shows that patients actually benefit if this is done in the first-line setting. For example, there was some preclinical data showing that even FOLFIRI, for example, can upregulate RAS, which would make tumors more resistant to this combination. This was thought to be practice-changing in a patient that has B600E showing up treatment naive that we should probably consider this regimen. And actually this did receive accelerated FDA approval about a month ago. Dr. Shaalan Beg: Yeah, and for what it's worth, I put up a Twitter poll asking my Twitter followers on how the BREAKWATER trial results will change their approach for newly diagnosed BRAF mutated colorectal cancer. We got 112 responses; 72% said that they will incorporate encorafenib, cetuximab, FOLFOX for their frontline BRAF mutated patients. But 23% said that they would like to wait for overall survival results. Dr. David Wang: Wow, that's interesting. They really want that 1x10 to the -8. Dr. Shaalan Beg: I guess so. All right. Let's change gears and talk about esophageal cancer. LBA329 was the SCIENCE study which presented preliminary results from a randomized phase 3 trial comparing sintilimab and chemoradiotherapy plus sintilimab versus chemoradiotherapy for neoadjuvant resectable locally advanced squamous esophageal cancer. Where are we in this space? Dr. David Wang: Okay. So, yeah, this was an interesting trial. Again, just to set the context, esophageal squamous cell carcinoma is more prevalent in Asia. And the study sites as well as the patients were mostly from Asia. So this was again a phase 3 trial with interim results. They only rolled 146 out of the planned 420 for this interim analysis. And yeah, they're using immune checkpoint inhibitor that we don't use in the United States, sintilimab, combined with their two standards of neoadjuvant therapy, either chemotherapy, which is more common in Asia, or or chemoradiation, which is more common in the US and Western Europe, versus chemoradiation. And so they actually had two primary endpoints, but only were reporting one. So their two primary endpoints were pathCR and the other one was event-free survival. The event-free survival, again, was not reported at the meeting.  What they found was that in terms of pathCR rate, if you take the two arms that are really informative about that, chemoradiation plus sintilimab versus chemoradiation alone, the pathCR rate was 60% versus 47%. We know that chemo alone doesn't induce as much of a pathCR rate, and that was 13%. So it was found that the delta in terms of pathCR between the chemoradiation arms, one with sintilimab and one without, was significant. And this actually confirms data again from Asia, like for the ESCORT-NEO trial where it used another immune checkpoint inhibitor pembrolizumab in addition to neoadjuvant chemo.  So as our discussant for this abstract said, yes, we know that radiation combined with chemotherapy improves pathCR rates, but we have recent data from the ESOPEC trial, we don't know that that necessarily will translate to overall survival. So again, waiting for additional enrollments and longer term follow up before incorporating this into clinical care here. Dr. Shaalan Beg: So David, how do the results of the SCIENCE trial compare with our practice in the United States and ongoing studies asking questions for neoadjuvant therapy for esophageal carcinoma in the United States? Dr. David Wang: I think obviously immune checkpoint inhibitor in the new adjuvant setting is important. Jennifer Eads at UPenn is running that EA2174 which is looking at chemoradiation plus or minus nivolumab, and then in non-pathCR responders randomized to adjuvant nivolumab per CheckMate 577 or nivolumab with intensification adding ipilimumab. We know that the ESOPEC trial just came out, and was published actually during the meeting, and that really focuses on adenocarcinomas. So adenocarcinomas of the GE junction, distal esophagus, now, we would probably treat very similarly to gastric using perioperative FLOT. However, the standard in the US for esophageal squamous cell carcinoma remains neoadjuvant chemoradiation. We know that squamous cell carcinomas are more exquisitely sensitive to radiotherapy. And then obviously in those patients who don't achieve a pathologic complete response, the expectation would be that they would go on to receive nivolumab per CheckMate 577. Again, the thought is that these tumors are more sensitive to immunotherapy given their higher incidences of mutational changes. And so again, this kind of goes along with the positive results seen in the SCIENCE trial that we just discussed with sintilimab but also EFFECT-neo with pembrolizumab. Obviously, we await the results of Jennifer's trial. Dr. Shaalan Beg: And the last abstract I was hoping we could get your perspective on was Abstract 652, which is a Phase 3 study of everolimus plus lanreotide versus everolimus monotherapy for unresectable or recurrent gastroenteropancreatic neuroendocrine tumors, the STARTER-NET trial. What were the results of this study? Dr. David Wang: So, I just want to give a shout out because we did have a session at this year's GI ASCO that looked at more rare tumors. So appendiceal tumors, neuroendocrine tumors, those kinds of things. So again, I would encourage your listeners to listen to that session if they have interest in that. Another type of rare tumor was adenosquamous tumors.  But in terms of the STARTER-NET trial, this was again an interim analysis of his phase 3trial and it was looking at combining everolimus plus lanreotide versus everolimus. So we know that in pancreatic-gastric neuroendocrine tumors, if you have low Ki-67, a well differentiated tumor, that the standard of care really is a somatostatin analog, and sometimes if they're more aggressive, we kind of consider molecular targeted therapy with everolimus. This was asking the question of whether we should do the combination on the frontline. And what was interesting is in this study, the patients were actually more of a poor prognostic set. So they had Ki-67 up to 20% or these were patients that actually had multiple liver lesions. And what they found was a median for progression free survival was improved with a combination out to 29.7 months versus 11.5 months with the somatostatin analog alone, and that the overall response rate was 23% versus 8.3%, again, favoring the combination. If you looked at subgroup analysis, it was actually those patients who had Ki-67 greater than 10%, so the more aggressive tumors, or those with diffuse liver lesions that had the most benefit. So I think that would be the patient population I would consider this new combination with using would be those patients again with poorer prognosis neuroendocrine tumor phenotype. Dr. Shaalan Beg: Thank you very much, Dr. Wang, for sharing your insights with us today and your great work to build a robust GI Cancers Symposium this year. Dr. David Wang: Well, thank you. I mean that really is a cooperative effort. We appreciate all the members of the GI25 Program Committee as well as the ASCO staff that just made it an outstanding meeting. Dr. Shaalan Beg: And thank you to all our listeners for your time today. You'll find links to the abstracts discussed today on the transcript of this episode.  Finally, if you value the insights that you hear on the ASCO Daily News Podcast, please take a moment to rate, review and subscribe wherever you get your podcasts. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement. Find out more about today's speakers:  Dr. Shaalan Beg @ShaalanBeg  Dr. David Wang Follow ASCO on social media:   @ASCO on Twitter  @ASCO on BlueSky ASCO on Facebook   ASCO on LinkedIn   Disclosures:  Dr. Shaalan Beg:  Employment: Science 37  Consulting or Advisory Role: Ipsen, Array BioPharma, AstraZeneca/MedImmune, Cancer Commons, Legend Biotech, Foundation Medicine  Research Funding (Inst.): Bristol-Myers Squibb, AstraZeneca/MedImmune, Merck Serono, Five Prime Therapeutics, MedImmune, Genentech, Immunesensor, Tolero Pharmaceuticals  Dr. David Wang: Honoraria:  Novartis Consulting or Advisory Role: Novartis, Cardinal Health, Bristol-Myers Squibb, BeiGene, Eisai  

Dr. Jasmine Sukumar and Dr. Dionisia Quiroga discuss advances in adjuvant therapy for patients with early breast cancer and BRCA1/2 mutations, including how to identify patients who should receive genetic testing and the significant survival benefits of olaparib that emerged from the OlympiA trial. TRANSCRIPT Dr. Jasmine Sukumar: Hello, I'm Dr. Jasmine Sukumar, your guest host of the ASCO Daily News Podcast today. I'm an assistant professor and breast medical oncologist at the University of Texas MD Anderson Cancer Center. On today's episode, we'll be exploring advances in adjuvant therapy for high-risk early breast cancer in people with BRCA1/2 germline mutations. Joining me for this discussion is Dr. Dionisa Quiroga, an assistant professor and breast medical oncologist at the Ohio State University Comprehensive Cancer Center.  Our full disclosures are available in the transcript of this episode.  Dr. Quiroga, it's great to have you on the podcast. Thanks for being here. Dr. Dionisia Quiroga: Thank you. Looking forward to discussing this important topic. Dr. Jasmine Sukumar: Let's start by going over who should be tested for BRCA1/2 genetic mutations. How do you identify patients with breast cancer in your clinic who should be offered BRCA1/2 genetic testing? Dr. Dionisia Quiroga: So, guidelines on who to offer testing to somewhat differ between organizations at this point. I would say, generally, I do follow our current ASCO-Society of Surgical Oncology (SSO) Guidelines, though. Those guidelines recommend that BRCA1/2 mutation testing be offered to all patients who are diagnosed with breast cancer and are 65 years old or younger. For those that are older than 65 years old, there are additional factors to really take into account to decide on who to recommend testing for. Some of this has to do with personal and family history as well as ancestry. The NCCN also has their own specific guidelines for who to offer testing to. For example, people assigned male at birth; those who are found to have a second breast primary; those who are diagnosed at a young age; and those with significant family history should also be offered BRCA1/2 testing.  I think, very important for our discussion today, ASCO and SSO also made a very important point that all patients who may be eligible for PARP inhibitor therapy should be offered testing. So clearly this includes a large amount of our patient population. In my practice, we often refer to our Cancer Genetics Program. We're fortunate to have many experienced genetic counselors who can complete pre-test and post-test counseling with our patients. However, in settings where this may not be accessible to patients, it can also be appropriate for oncology providers to order the testing and ideally perform some of this counseling as well. Dr. Jasmine Sukumar: Thank you Dr. Quiroga. Let's next review where we are in current clinical practice guidelines. What current options do we have for adjuvant therapy specific to people with high-risk early breast cancer and BRCA1/2 genetic mutations? Dr. Dionisia Quiroga: Our current guidelines recommend adjuvant olaparib for one year for individuals with HER2-negative high risk breast cancer. This approval largely came from the data and the results of the OlympiA trial. This was a prospective phase 3, double blind, randomized clinical trial. It enrolled patients who had been diagnosed with HER2-negative early-stage breast cancer who also carried germline pathogenic or likely pathogenic variants of either the BRCA1 and/or BRCA2 genes. The disease also had to be considered high-risk and there were several criteria that had to be evaluated to deem whether or not these patients were high-risk. For example, those who are treated with neoadjuvant chemotherapy, if they had disease that was triple-negative, they needed to have some level of invasive residual disease at time of surgery. Alternatively, if the disease was hormone receptor-positive, they needed to have residual disease and a calculated CPS + EG score of 3 or higher. This scoring system is something that estimates relapse probability on the basis of clinical and pathologic stage, ER status, and histologic grade, and this will give you a score ranging from 0 to 6. In general, the higher the score, the worse the prognosis. This calculator though is available to the public online to allow providers to calculate this risk.  For the subset of patients who received adjuvant chemotherapy, for them to qualify for the OlympiA trial, if they had triple-negative disease, they needed to have a tumor of at least 2 cm or greater and/or have positive lymph nodes for disease. For hormone receptor-positive disease that was treated with adjuvant chemotherapy, they were required to have four or more pathologically confirmed positive lymph nodes at time of surgery. From this specified pool, patients were then randomized 1:1 to get either adjuvant olaparib starting at 300 mg twice a day or a matching placebo twice a day after they had completed surgery, chemotherapy and radiation treatment if needed. Dr. Jasmine Sukumar: And what were the outcomes of this study? Dr. Dionisia Quiroga: The study ended up enrolling over 1,800 patients and from these 1,800 patients, 70% had a BRCA1 mutation while 30% had a BRCA2 mutation. About 80% of the patients had triple-negative disease compared to hormone receptor-positive disease. Interestingly, about half of all patients enrolled had received neoadjuvant chemotherapy while the other half received adjuvant chemotherapy.  Looking at the outcomes, this was overall a very positive study. We actually now have outcomes data from a median of about 6 years out. This was just reported in December at the 2024 San Antonio Breast Cancer Symposium. There was found to be a 9.4% absolute difference in six-year invasive disease-free survival favoring the olaparib arm over the placebo arm. What was also interesting is that this was consistent across multiple subgroups of patients and the benefit was really seen whether or not they had hormone receptor-positive or triple-negative disease. The absolute difference in distant disease-free survival was also high at 7.8% and additionally favored olaparib. Most importantly, there was found to be a significant overall survival benefit. The six-year overall survival was 87.5% in the olaparib group compared to 83.2% in the placebo group. This translates to about a 4.4% difference and a relative 28% overall survival benefit in using olaparib.  Now, future follow up is going to be very important. Follow up for this study is actually planned to continue out until June 2029 so we can continue to observe if these survival curves will continue to branch apart as they have so far at each follow up. And I think this is especially important for those patients diagnosed with hormone receptor-positive cancers because we know those patients are at particular risk for later recurrences.  As an additional side note, the researchers also noted that there were fewer primary malignancies in the olaparib group, not just of the breast but also primary ovarian or fallopian tube cancers as well, which is not completely surprising knowing that this drug is also heavily used and beneficial in different types of gynecologic cancers. Ultimately, the amount of adverse events reported have been low with only about 9.9% of patients receiving olaparib needing to discontinue drug due to adverse events, and this is compared to 4.2% reported in the placebo group. Dr. Jasmine Sukumar: You mentioned that the OlympiA trial showed an overall survival benefit, but interestingly the OlympiAD trial looking at olaparib versus chemotherapy in patients with advanced metastatic HER2-negative breast cancer did not show a significant overall survival benefit. Could you discuss those differences? Dr. Dionisia Quiroga: I agree, that's a very good point. So OlympiA's comparator arm was, of course, a placebo. So while this isn't the same as comparing to chemotherapy, it does still potentially suggest that there is a degree of benefit that olaparib can provide when it's introduced in the early local disease setting compared to advanced metastatic disease. I think we need more future trials looking at potential other combinations to see if we can improve the efficacy of PARP inhibitors in the metastatic setting. Dr. Jasmine Sukumar: For patients who do choose to proceed with use of adjuvant olaparib due to the promising efficacy, what side effects should oncologists counsel their patients about? Dr. Dionisia Quiroga: The most common notable side effects, I would say with olaparib and other PARP inhibitors are really cytopenias. Gastrointestinal side effects such as nausea and vomiting can occur as well as fatigue. There are some less common but potentially more serious side effects that we should counsel our patients on. This includes pneumonitis. So counseling patients on if they're short of breath or experiencing cough to let their provider know. Venous thromboembolism can also be increased rates of occurrence. And then of course myelodysplastic syndromes or acute myeloid leukemia is something that we often are concerned about. That being said, I think it should be noted that interestingly in the OlympiA trial so far, there have been less new cases of MDS and AML in the olaparib group than actually what's been reported in the placebo group at this median follow up of over six years out. So we'll need to continue to monitor this endpoint over time, but I do think this provides some reassurance. Dr. Jasmine Sukumar: Since the initiation of the OlympiA trial, other adjuvant treatments have also been studied and FDA approved for non-metastatic HER2-negative breast cancer. So for example, the CREATE-X trial established adjuvant capecitabine as an FDA approved treatment option in patients with triple-negative breast cancer who had residual disease following neoadjuvant chemotherapy. So if a patient with triple-negative breast cancer with residual disease is eligible for both adjuvant olaparib and adjuvant capecitabine treatments, how do you decide amongst the two? Dr. Dionisia Quiroga: If a patient's eligible for both, I honestly often favor olaparib, and I do this because I find the data for adjuvant olaparib a little bit more compelling. There are also differences in toxicity profile and treatment duration between the two that I think we should discuss with patients. For example, olaparib is supposed to be taken for a year total, whereas with capecitabine we typically treat for six to eight cycles with each cycle taking three weeks. There are some who may also sequence the two drugs in very high-risk disease. However, this is very much a data free zone. We don't have any current clinical trials really comparing these two or if sequencing of these agents is appropriate. So I don't currently do this in my own clinical practice. Dr. Jasmine Sukumar: Nowadays, almost all patients with stage 2 to 3 triple-negative breast cancer will be offered neoadjuvant chemotherapy plus immune checkpoint inhibitor therapy pembrolizumab per our KEYNOTE-522 trial data. With our current approach, pembrolizumab is continued into the adjuvant setting regardless of surgical outcome, so that patients receive a year total of immunotherapy. So in patients with residual disease and a BRCA germline mutation, do you suggest using adjuvant olaparib concurrently with pembrolizumab? Do we have any data to support that approach? Dr. Dionisia Quiroga: I do. I do use them concurrently. If a patient is eligible for adjuvant olaparib, I would use it the same way as if they were not on pembrolizumab. That being said, there are no large studies currently that have shown what the benefit or the toxicity of pembrolizumab plus olaparib are for early-stage disease. However, we do have some safety data of this combinatorial approach from other studies. For example, the phase 2/3 KEYLYNK-009 study showed that patients with advanced metastatic triple-negative breast cancer who were receiving concurrent pembrolizumab and olaparib had a manageable safety profile, particularly as the toxicities of these drugs alone don't tend to overlap. Dr. Jasmine Sukumar: And what about endocrine therapy for those that also have hormone receptor-positive disease? Dr. Dionisia Quiroga: Adjuvant endocrine therapy should definitely be continued while patients are on olaparib if they're hormone receptor-positive. An important component of this will also likely be ovarian suppression, which should include recommendation of risk reducing bilateral salpingo oophorectomy due to the risk of ovarian cancer development in patients who carry BRCA1/2 gene mutations. In most cases, this should happen at age 40 or before for those that carry a BRCA1 mutation, and at age 45 or prior for those with BRCA2 mutations. Dr. Jasmine Sukumar: And do you also consider adjuvant bisphosphonates in this context? Dr. Dionisia Quiroga: Yes. Like adjuvant endocrine therapy, adjuvant bisphosphonates were also instructed to be given according to standard guidelines in the OlympiA trial, so I would recommend use of bisphosphonates when indicated. You can refer to the ASCO Ontario Health Guidelines on Adjuvant Bone-Modifying Therapy Breast Cancer to guide that decision in order to utilize this due to multiple clinical benefits. It doesn't just help in terms of adjuvant breast cancer treatment but also reduction of fracture rate and down the line, improved breast cancer mortality.  Dr. Jasmine Sukumar: Particularly in hormone receptor-positive breast cancer, another adjuvant therapy option that was not available when the OlympiA trial started are the CDK4/6 inhibitors, ribociclib and abemaciclib, based on the NATALEE and monarchE studies. So how do you consider the use of these adjuvant therapy drugs in the context of olaparib and BRCA mutations? Dr. Dionisia Quiroga: Yeah, so we are definitely in a data-free zone here. And that's in part because the NATALEE and the monarchE studies are still ongoing and reporting data out at the same time that we're getting updated OlympiA data. So unlike some of our other adjuvant treatments that we discussed, where olaparib could be safely given concurrently, the risk of myelosuppression and using both a CDK4/6 inhibitor and a PARP inhibitor at the same time would be too high. In some cases, even if a patient has a BRCA1/2 mutation, they may not meet that specified inclusion criteria that OlympiA set for what they consider to be high-risk disease. And we know from the NATALEE and the monarchE trial there are also different markers that they use to denote high-risk disease. So it's possible, for example, in the NATALEE trial that looks specifically at adjuvant ribociclib, they included a much larger pool of hormone receptor-positive early-stage breast cancers, including a subset that did not have positive axillary lymph nodes.  In cases where patients would qualify for both olaparib and a CDK4/6 inhibitor, I think this is worth a nuanced discussion with our patients about the potential benefits, risks and administration of these drugs. I think another point to bring up is the cost associated with these drugs and the length of time patients will be on for, because financial toxicity is always something that we should bring up with patients as well. When sequencing these in high-risk disease, my practice is to generally favor olaparib first due to the overall survival data. There is also some data to support that patients with BRCA1/2 germline mutations may not respond quite as well to CDK4/6 inhibitors compared to those without. But again, this is still outside of the purview of current guidelines. Fortunately, we have more potential choices for patients, and that's a good thing, but shared decision making also needs to be key. Dr. Jasmine Sukumar: And while our focus today is on adjuvant treatment for people who carry germline BRCA mutations, what about other related gene mutations such as PALB2 pathogenic variant? Dr. Dionisia Quiroga: That's a great question. Clinical trials in the advanced metastatic setting have shown that there is efficacy of olaparib in the setting for PALB2 mutations. This is largely based on the TBCRC 048 phase 2 trial and that provided a Category 2B NCCN recommendation for patients with these PALB2 gene mutations. However, we're really still lacking enough clinical data for use in early-stage disease, so I don't currently use adjuvant olaparib in this case. I am definitely eager for more data in this area as the efficacy of PARP inhibitors in PALB2 gene mutations is very compelling. I think also, in the same line, there's been some data for somatic BRCA1/2 mutations in the metastatic setting, but we still have a lack of data for the early stage setting here as well. Dr. Jasmine Sukumar: Thank you Dr. Quiroga, for sharing your valuable insights with us today on the ASCO Daily News Podcast. Dr. Dionisia Quiroga: Thank you, Dr. Sukumar. Dr. Jasmine Sukumar: And thank you to our listeners for your time today. You'll find links to the studies discussed today in the transcript of this episode. Finally, if you value the insights that you hear on the ASCO Daily News Podcast, please take a moment to rate, review and subscribe wherever you get your podcasts. Thank you. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Follow today's speakers:   Dr. Dionisa Quiroga @quirogad @quirogad.bsky.social Dr. Jasmine Sukumar @JasmineSukumar  @jasmine.sukumar.bsky.social Follow ASCO on social media:  @ASCO on X   @ASCO on Bluesky    ASCO on Facebook    ASCO on LinkedIn    Disclosures: Dr. Dionisia Quiroga:  No relationships to disclose Dr. Jasmine Sukumar: Honoraria: Sanofi (Immediate Family Member)  

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/first-line-advanced-gastric-cancer-best-practices-for-biomarker-directed-treatment-approachesa-case-study/29848/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/expert-opinion-key-insights-on-gi-malignanciesintegrating-nccn-clinical-practice-guidelines-into-practice/29855/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/novel-neoadjuvant-and-adjuvant-immunotherapy-strategies-for-gi-malignancies-the-evidence/29854/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/emerging-directions-in-biomarker-directed-therapy-for-gi-malignancies/29853/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/current-guideline-recommendations-for-biomarker-based-second-line-treatment-of-mcrc/29851/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/first-line-treatment-of-msi-hdmmr-mcrc-the-role-of-immunotherapy/29850/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/immunotherapy-based-approaches-for-first-line-treatment-of-advanced-hcc-the-evidence/29849/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/applying-current-guidelines-in-the-first-line-treatment-of-msi-hdmmr-mcrca-case-discussion/29852/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/the-role-of-biomarker-driven-therapies-in-the-second-line-treatment-of-advanced-gastricgej-cancers-what-do-the-data-say/29847/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.25 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/biomarker-directed-approaches-for-frontline-treatment-of-advanced-gastricgej-cancers-the-evidence/29846/ The NCCN Clinical Practice Guidelines are crucial tool in the treatment of cancer and provide detailed recommendations for treatment selection. The guidelines are regularly updated as new therapies are approved or as drugs received expanded indications. Moreover, data are constantly evolving regarding the role of biomarkers and treatment choice. This activity has been designed to provide an overview of the NCCN guidelines for gastric, colorectal, and hepatocellular cancers and the optimal application of these recommendations to clinical practice.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/management-of-her2-low-mbc-following-first-line-disease-progression/29834/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/management-of-hr-her2-high-risk-ebc/29833/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/immunotherapy-for-tnbc-in-the-perioperative-setting-clinical-evidence-and-considerations/29825/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/expert-viewpoint-optimizing-breast-cancer-treatment/29832/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/the-evolving-treatment-landscape-for-mbc-emerging-therapies/29831/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/emerging-treatment-approaches-for-ebc/29830/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/adjuvant-treatments-for-hrher2-ebc-the-role-of-cdk46-and-parp-inhibitors/29826/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/clinical-implications-of-current-guidelines-on-first-line-immunotherapy-and-parp-inhibitors-for-tnbc/29827/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/the-role-of-her2-directed-therapy-for-second-line-treatment-of-her2-metastatic-breast-cancer/29828/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.50 Valid until: 30-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/guideline-recommendations-for-the-definition-and-treatment-of-her2-low-breast-cancer/29829/ Treatment decision-making in breast cancer is complex and incorporates several factors including disease- and patient-related characteristics. The NCCN Clinical Practice Guidelines are regularly updated to provide the most accurate recommendations based on recent scientific evidence and drug approvals. This activity has been designed to review the current NCCN guidelines and the supporting data and explore best practices for selecting therapy based on these recommendations. Explore guideline-based strategies and clinical data to optimize guideline-adherent care for patients with CLL/SLL and MCL.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/insights-from-global-key-opinion-leaders-on-optimizing-patient-care-in-genitourinary-malignancies/29202/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/emerging-immunotherapy-combination-strategies-in-genitourinary-malignancies/29201/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/guideline-recommended-second-line-treatment-following-an-immune-checkpoint-inhibitor-in-renal-cell-carcinoma/29199/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/emerging-targeted-therapy-combination-strategies-in-genitourinary-malignancies/29200/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/guideline-recommended-first-line-treatment-with-immunotherapy-and-targeted-therapy-combinations-in-renal-cell-carcinoma/29198/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/incorporation-of-guideline-recommendations-into-the-frontline-care-of-a-patient-with-mcrpc-who-is-naive-to-both-docetaxel-and-novel-hormone-therapy/29197/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/guideline-recommendations-for-first-line-treatment-intensification-with-parp-inhibitor-combinations-in-patients-with-metastatic-castration-resistant-prostate-cancer/29196/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/incorporation-of-guideline-concordant-care-for-first-line-treatment-of-a-patient-with-metastatic-urothelial-carcinoma/29195/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/clinical-evidence-driving-guideline-recommendations-for-monotherapy-in-the-second-line-or-later-setting-in-metastatic-urothelial-cancer/29194/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

CME credits: 1.25 Valid until: 20-12-2025 Claim your CME credit at https://reachmd.com/programs/cme/clinical-evidence-driving-guideline-recommendations-for-frontline-immunotherapy-based-combination-regimens-in-metastatic-urothelial-cancer/29193/ This online CME activity, presented in collaboration with the National Comprehensive Cancer Network (NCCN®), focuses on translating oncology clinical practice guidelines into practical strategies for treating genitourinary malignancies. Participants will learn how to integrate clinical trial data into guideline-concordant first- and subsequent-line treatment plans for patients with metastatic urothelial cancer (UC), metastatic castration-resistant prostate cancer (mCRPC), and metastatic renal cell carcinoma (RCC). The program highlights the importance of evidence-based approaches and the use of immunotherapy and targeted therapies for advanced genitourinary malignancies. Attendees will also explore emerging data that could influence future treatment guidelines, patient case examples, and insights from international faculty to develop region-specific therapeutic strategies aligned with NCCN recommendations.

肺癌已是台灣癌症發生與死亡的雙冠王！根據110年癌症登記報告顯示，肺癌的新發個案數在35歲後顯著上升，且50歲以上肺癌患者更佔了八成。而近來肺癌患者確診仍為早期比例上升 ，早期肺癌經手術治療後成效雖佳。不過術後仍有四成復發風險 ，手術後的復發率，與病理肺癌分期嚴重度成正相關。近年來，免疫治療除了應用在晚期肺癌治療之外，也開始進入早期肺癌輔助治療領域。美國癌症治療指引(NCCN)已將免疫輔助治療納入的治療建議，其中「早期肺癌包圍術」更是輔助治療中的首選。 究竟現今醫學上，肺癌早期治療都開啟哪些新曙光？請下載收聽本集「銀天下」！ 主持人：銀天下資深副總編輯 林倖妃 來賓：長庚醫院 趙盈凱醫師 製作團隊：天下實驗室、天下整合傳播部 本集節目由默沙東合作推薦

For a probing discussion detailing the American Lung Association's recent 2024 “State of Lung Cancer” report, we are joined by esteemed thoracic medical oncologist Dr. Jacob Sands of Dana-Farber Cancer Institute and Harvard Medical School. Offering insight into actionable targeted mutations, Dr. Sands addresses how precision oncology is fundamentally changing lung cancer diagnosis and treatment. The novel immunotherapy drugs, though proven to be safe and effective with significant improvements in response and survival rates, have challenges as well—this episode covers the gamut. Episode Highlights 0:00 Start 1:00 Topic of discussion 2:42 Introducing Jacob Sands, MD 3:39 NCCN guidelines for lung cancer 6:51 Recently-approved drugs for lung cancer 13:46 Patient responses to targeted mutations 17:58 Off-target side effects with drugs 21:34 State of Lung Cancer report 23:04 Estimated number of candidates for targeted therapies 26:13 Insurance coverage for biomarker testing 28:12 Other issues with ordering biomarkers 31:20 Closing comments 32:36 Outro Want more Lungcast? Visit us at HCPLive.com/podcasts/lungcast or www.lung.org/professional-education/lungcast

On today's episode, we are discussing a topic that affects most women with hormone receptor-positive, early-stage breast cancer after they finish their initial treatment and begin navigating survivorship. To lower the risk of recurrence, most women begin taking anti-estrogen therapy, also called hormone therapy or endocrine therapy, but these treatments do not come without the risk of side effects. When side effects become severe, survivors may be faced with the task of weighing the benefits of hormone therapy against the associated side effects. This can be challenging and may even lead them to wonder how much longer they need to continue on the medication. Joining us today to discuss how patients and providers can balance fear of recurrence against potential side effects of treatment and how genomic testing can help guide treatment decisions is a Nurse Practitioner at Memorial Sloan-Kettering Cancer Center, Adriana Olivo. This podcast is sponsored by Biotheranostics Inc., a Hologic Company. The Breast Cancer Index test is the only test recognized by the NCCN guidelines and the ASCO Clinical Practice Guideline to predict which patients are likely to benefit from extension of adjuvant anti-estrogen therapy beyond 5 years.

JCO PO author Dr. Michael J. Hall, Professor of Medicine, Chairman of the Department of Clinical Genetics, and Co-Leader of the Cancer Prevention and Control Program at Fox Chase Cancer Center in Philadelphia, PA, shares insights into the JCO PO article, “Uptake of aspirin chemoprevention in patients with Lynch Syndrome.” Host Dr. Rafeh Naqash and Dr. Hall discuss the finding that only about 1 in 3 patients with Lynch Syndrome use aspirin for cancer chemoprevention. TRANSCRIPT  Dr. Rafeh Naqash: Hello and welcome to JCO Precision Oncology Conversations, where we bring you engaging conversations with authors of clinically relevant and highly significant JCO PO articles. I'm your host, Dr. Rafeh Naqash podcast editor for JCO Precision Oncology and Assistant Professor at the OU Health Stephenson Cancer Center at the University of Oklahoma. Today, I'm excited to be joined by Dr. Michael J. Hall, Professor of Medicine, Chairman of the Department of Clinical Genetics and co-leader of the Cancer Prevention and Control Program at the Fox Chase Cancer Center in Philadelphia, and also the lead author of the JCO Precision Oncology article entitled, “Uptake of Aspirin Chemo Prevention in Patients with Lynch Syndrome.” At the time of this recording, our guest disclosures will be linked in the transcript. Dr. Hall, welcome to the podcast and thank you for joining us today to explain and help the listeners understand your interesting research that was just published in JCO Precision Oncology. Dr. Michael J. Hall: Thank you so much for having me and really thanks for the interest in our work. I think it's an important subject and I hope people will also find it as interesting as we do. Dr. Rafeh Naqash: Absolutely. I think your research touches upon a few things. One, obviously, touches upon Lynch syndrome germline assessments of individuals. It also touches upon chemo prevention, prevention in general, and it also touches upon the knowledge and understanding of chemo prevention aspects. So to start off, I would like to ask you, for the sake of our listeners, many of whom who may not necessarily fully understand the length and breadth of Lynch syndrome, maybe perhaps some residents or trainees out there, could you tell us what Lynch syndrome is, what some of the mutations are, what the implications are, and then we can try to go and delve more into the research topic. Dr. Michael J. Hall: Sure, I'd be happy to. Lynch syndrome is probably, in the hereditary cancer genetics world, one of the most common hereditary risk syndromes we encounter. Recent estimates are that probably roughly about 1 in every 280 individuals in the population is a carrier of a pathogenic variant, one of the Lynch syndrome genes, there are roughly four. There's sort of a fifth gene that is also involved with Lynch syndrome, but really, we largely think about four genes in Lynch syndrome, MLH1, MSH2, MSH6, and PMS2. Over time we've begun to learn, and I'll say that the guidelines that we develop have become more specialized for each of those genes. They are not sort of all the same in the cancers they cause and the way they behave. But roughly, what is Lynch syndrome? It's a syndrome of DNA mismatch repair. So, individuals who have Lynch syndrome have some degree of deficiency in their ability to repair DNA via the mismatch repair system. Depending on the pathogenic variant that is within a family, that may be related to a more severe deficiency of mismatch repair, repair, editing, or for instance, with the PMS2 gene, we've learned over time that actually the degree of DNA repair deficiency is actually a milder phenotype. These individuals over a lifetime are at risk of a variety of different kinds of cancers, the most common being colon cancer. And the risk of that is variable by gene. With MLH1 and MSH2, it's close to 50% over a lifetime. With MSH6 and PMS2, somewhat lower. There are also risks of endometrial cancer, gastric cancer, ovarian cancer, pancreas cancer, a number of other ones. But they're all related again to the same underlying molecular deficiency, and that's this deficiency of being able to repair mistakes made in the DNA accurately. And so, mutations accumulate in the genome of cells in various tissues of the body. Dr. Rafeh Naqash: Thank you for that very simplified version of a very complicated topic otherwise. So, as you mentioned, these different genes have different implications. Perhaps some have higher risks for colorectal cancer than others. What are some of the current standardized approaches for screening or following these individuals over the course of their journey until perhaps either get detected with cancer or while they're being monitored? Dr. Michael J. Hall: Sure. It's a great question, because this is very much a moving target in this disease. I'm going to give you a quick second of history that up until maybe about six or seven years ago, we had uniform guidelines, really, that any Lynch syndrome pathogenic variant carrier should start colorectal cancer screening. Usually, we were recommending between the age of 20 and 25, and this was usually annual colonoscopy. And for years that was the standard. In more recent years, we've stuck to that tight interval, particularly in the higher risk genes, MLH1 and MSH2, although the guideline now reads every one to two years, because we recognize people need some degree of flexibility to live their lives. And there are people in the population who are more risk averse, and there are those who want a colonoscopy every year because they want to stick to that schedule. For MSH6, we recommend a somewhat later start at age 30, and that can be every one to three years for colon screening and for PMS2, similar recommendations, although I think there is a chance in the coming years, we may actually expand the screening interval even more, again, because the risks are somewhat lower. We still have ways to go in terms of screening for the other cancers in Lynch syndrome. I'll say that, for instance, endometrial cancer, which is the second most common cancer in this disease, we still struggle with what is the best way to screen women for a risk of endometrial cancer. Our guidelines in the past were always somewhat draconian, that once women sort of finish childbearing, they should immediately have a total abdominal hysterectomy and oophorectomy. And I'll say that with greater input from the gynecologic and GYN ONC community, we have somewhat softened those recommendations, especially for the endometrial cancer and also the age at oophorectomy, because we recognize that there were compensatory risks of taking the ovaries out too early in some women, risks of bone loss and cardiovascular disease. So those are the most common. For other tumors in Lynch syndrome, for instance, gastric cancer and pancreas cancer, the guidelines are still really evolving, and different groups have put out guidance for clinicians. And I'll say NCCN, which I participate in and help write those guidelines, has very good recommendations for docs. But I'll say that it is again, back to the idea that it's a moving target. And as we learn more, hopefully, we'll have better recommendations. Dr. Rafeh Naqash: I completely agree as far as a moving target is concerned, and we often look at the disconnect between the recommendations and then what's implemented or followed in the real-world setting. So I have a question in that context, and my question is, when you identify these individuals with Lynch syndrome, perhaps let's talk about academic settings, and then we can try to delve into how this might work in the real world community oncology settings, where the real world population actually exists, 60, 70% of individuals get treated in the community. So, when you talk about an academic center, what is the flow of the individual? Does the individual stay within the geneticist when they're diagnosed? Does the individual go to the primary care and the geneticist makes the recommendation and the primary care follows the recommendation? How does it work for you and what are some of the models that you've seen work best perhaps at different academic centers? Dr. Michael J. Hall: I think you get at a really great question. And I'll say there is really no one model. And I think models have to be fluid these days because people with Lynch syndrome are really being identified in more and more diverse settings, and by diverse means. I'll say at my own center, we are more of a traditional practice. So, we do the pre-test and the post-test counseling. Once we have counseled individuals identified Lynch syndrome, we will usually make referrals. If folks don't have a gastroenterologist that they have interacted with before, we keep them in our own group and follow them. But their Lynch syndrome home really sits both in a continuity clinic that I run for patients to come back and circle around every one to two years just to review guidelines and review their screening results. However, I do really make an effort to, first of all, keep primary care docs involved, because I think some of the things we recommend, it is critical that the primary care doc is aware so that patients are keeping up with some of the recommendations. For instance, we often recommend skin screening to make sure that folks have had at least one good skin exam somewhere in the 40s. And I think the primary care doc can be very helpful in making sure that happens. It is somewhat different, I think, in the community where many more patients with Lynch syndrome are being identified these days. I suspect that much more of the burden of making sure Lynch syndrome patients are well hooked in with a gastroenterologist and with a dermatologist and maybe a urologist probably does fall on that primary care doctor. In my experience, some primary care physicians have really kind of jumped up in and taken hold of this and really know their Lynch syndrome well, and I think that's amazing. I do, however, as kind of an expert in this area, I do get a lot of referrals in from the community as well, from docs who just feel that they may not have quite that expertise that they can get at a comprehensive center. So, someone may come in to me just for a consult to review what my recommendations would be, hear about research, hear about what's going on in the field, and those folks will often touch base with me again every couple year or so. Often, another thing I've started to experience is that I may meet people once or twice early on in their diagnosis, and then they go back to their primary docs and I may not hear from them again until something more profound happens in the family or into the patient and they get their screening colonoscopy and a stage 1 cancer is found. Often then, that's the patient who, after four or five years, will contact me again and say, “We haven't talked in a while, but something has happened, and can we re-consult about what would be the best way to do things?” Dr. Rafeh Naqash: Again, like you said, lots of moving targets, moving aspects to this whole care of these individuals. Do you think, in your experience, nurse navigation, maybe some centers have already implemented that perhaps you might have that, do you think nurse navigation could play a certain level of role? You know how in the multidiscipline care we have nurse navigators that coordinate care between radiation oncologists, medical oncologists, thoracic surgeons. So that's something that is being implemented. My second part of that question is telehealth in this case, maybe it's a little more difficult for somebody to drive three hours to come to you for a visit just to check in versus maybe virtually talking to you or your team getting a sense of where things are at in terms of their screening and their follow ups. Dr. Michael J. Hall: I think both are great, great questions and absolutely, we use both of those pieces in our model. And I know from colleagues that they do as well. So, in terms of navigation, we do have an embedded nurse navigator within our department. She joins and kind of helps facilitate all of our high risk follow up clinics. Mine, for GI, we have a high-risk prostate clinic, we have several high-risk breast clinics and those are populated by providers. We have a couple of nurse practitioners in my genetics group and a PA they are sort of the main provider in those clinics, but they are very much supported by that nurse navigator who, as you well point out, really helps with the coordination of the care. Telehealth as well, I do 100% support because you're absolutely right, if you look at a map of the United States and you first of all look at where there are good counseling services available, of course, there's ample counseling in the major metropolitan areas all over the U.S., but the minute you get outside of those counseling and then other management expertise, then– So we do have a model where particularly for folks who are from central Pennsylvania and sometimes more towards western Pennsylvania, I do have some individuals who've been identified with Lynch syndrome who telehealth in, again, for that follow up. A sort of side notes on telehealth, I think we learned a lot from the pandemic about how to use telehealth more effectively. And thank goodness, we've all gotten up to speed in medicine of how to be better telehealth providers. Unfortunately, I feel like with the pandemic kind of waning, there's been a little bit of a regression of the telehealth laws. So now if I want to do telehealth with someone who is from New Jersey, even though New Jersey sits very close to where I practice, it's more complicated now. Again, I have to get a license and same thing with New York and same thing with Delaware. I sort of wish we had a little bit of a better and welcoming system in the states where you could have easier ability to practice, especially when states were quite close using telehealth. But nonetheless, that's for another podcast, I think. Dr. Rafeh Naqash: Well, thank you again for some of those interesting aspects to this whole topic. But let's dive into the thing that we are here to talk about, which is aspirin in these individuals. So can you give us some context of why aspirin, what's the biology there and what's the data there, and then talk about why you did what you did. Dr. Michael J. Hall: So, we've known for many years that aspirin has preventive properties in terms of preventing colorectal cancer. Many observational studies and some interventional studies have shown us that aspirin has benefits for reducing the risk of colon cancer in an average risk population. There was even an interventional trial a number of years ago that looked at individuals who made polyps, and this looked at particularly adenomas, which we know are the precancerous polyps and adenoma prevention using aspirin. And that study clearly showed that aspirin had benefits for lowering risk of recurrent polyps and adenomas. Particularly even a lower dose of aspirin, 81 milligrams, was effective in that setting. Aspirin's also been studied in other hereditary risk syndromes, the most visible one being FAP, where data have shown that aspirin does help reduce polyp count in FAP, although is certainly not a perfect chemo prevention for that disease. So, in that background of knowing that aspirin has many benefits for colorectal cancer prevention, a study was initiated in the UK a number of years ago called the CAPP2 study, with its lead investigator being John Burn. And in this study, it was a two-arm factorial study that was not just aspirin, but they were also looking at resistant starch, which there was a lot of excitement about resistant starch back then. But in this study, they looked at using aspirin as a way of lowering risk of colorectal cancer in patients with Lynch syndrome. And that study, which was initially reported in The New England Journal, the initial outcomes did not actually show benefits in its first analyses of adenoma risk and colon cancer risk. But what they found over time was that there was a delayed effect and, in a follow, up paper looking at 10 plus years of follow up, they showed a substantial reduction in risk of colon cancer, about 40% risk reduction, which was really striking and exciting in the field to see such a large benefit from aspirin. Now, one caveat was in the analyses they performed, it was those individuals who were able to stick to the aspirin dose in that study, which was 600 milligrams a day. I always say to folks that back in the day, that was not a lot of aspirin, although I think these days we're much more skeptical about taking larger doses of any drug. So, 600 milligrams is roughly about two adult aspirin in the U.S. So those folks who were able to stick to that dose for at least two years were the ones who gained benefit from being on aspirin. And what was interesting is that benefit endured for really 10 years after those two years of being able to take aspirin. So, this was striking and it really changed our thinking about whether there may be chemo prevention options for folks with Lynch syndrome. However, and I think what formed the background of our study here was that there was a somewhat equivocal endorsement of aspirin by the major guidelines committees, mainly because, as we all know in oncology, we love one first big study, but we always really love secondary studies that solidify the finding of the first study. And so, because this was such a niche group and no one else out there was doing big aspirin studies when this result came out in 2011, we've sort of been waiting for many years for some follow up data. And the NCCN guidelines have always been a little bit equivocal that people could consider using aspirin to lower risk in their patients with Lynch syndrome, but without that kind of strong, “Everyone should do this.” And so, this has kind of formed the background of why we performed the study that we did. Dr. Rafeh Naqash: Interesting. And then you had a bunch of observations. One of the most important ones being that use of aspirin was pretty low. Could you dive into that and help us understand what were some of the factors surrounding those low implementation aspects? Dr. Michael J. Hall: Of course. So, what we were interested in then again in that background was, here's a high-risk population, docs are getting somewhat maybe ambiguous information from the guidelines, but what actually is going on out there in practice? How many patients are actually using aspirin? What doses are they using, and what are some of the factors that drive it? So, we performed a survey that actually occurred in two parts. One started at Fox Chase in our population here, and then we expanded it online to a convenience sample. Overall, we had 296 respondents. And yeah, what we found actually was the uptake of aspirin was only about roughly 30%, 35% or so among patients who were eligible to take aspirin. When you actually drill down to those people actually taking aspirin because they wanted to prevent Lynch syndrome, it was even lower. It was in the range of 25% to 30%. This somewhat surprised us. And then when we looked at the doses that people were using, of course, thinking back to that 600-milligram dose that was tested in the study, we found actually that more than half of folks were taking low dose aspirin, like an 81 milligram, and only about 8% of our study participants were using that 600-milligram range. So, again, I would say this somewhat surprised us because we thought it might be higher than this. I'll say as a somewhat caveat to this though, is that back to my comment about we always like another study that confirms our findings, and at a meeting earlier this year, there was a study performed in a New Zealand population by a medical oncologist named Rebecca Tuckey. And she actually found almost the same identical results that we did in the New Zealand population - very, very similar uptake rates of aspirin in the New Zealand population with Lynch syndrome, so kind of confirming that something we've stumbled upon appears to be true. But how do we understand why some folks use aspirin and why others don't in this condition? Dr. Rafeh Naqash: You had a very robust question there from what I saw in the paper. And some of the questions that I had around that was, did you or were you able to account for demographics, education level of the individuals? Were you also able to assess whether these individuals felt that they had been counseled appropriately when they met with either a primary care physician or of any provider on the genetic side, physician or non-physician? So how did you get an assessment of whether it was an apples-to-apples comparison or were there a lot of confounders. Dr. Michael J. Hall: Very good question. And of course, in the setting, unfortunately, we weren't interviewing people, which we could have gotten much richer data in some ways. And there were other things we were looking at in this survey as well, so our aspirin questions, we had a number of them, but perhaps in retrospect, it would have been nice to even have more. We did have some common covariates, age, sex, ancestry, marital status, which gene was affected, whether they had a history of cancer. We did not have education, unfortunately. And I think your question is a great one, but we did not actually ask folks about whether they had been counseled by their provider or their genetic counselor or someone else about whether they should use aspirin or not. We simply wanted to see whether folks were using it. We did ask them again whether they were using it because they wanted to lower their risk of a Lynch syndrome cancer or whether they were using it for another reason or a combination of both. So, yes, in retrospect, we actually do have another study plan to kind of drill deeper into these questions of is it more of a hesitancy question? Is it more of a question of just not as much awareness? Are there other reasons? I think there's a lot to answer, and I think answering these questions is really important because we both want to make sure we're talking about interventions that we think can help people, but we need to understand also some of the barriers they may face. And if people do have barriers to some forms of chemo prevention or I think about some of the vaccine research that's going on right now, if the kinds of things that we're working on to develop are actually not going to be palatable to the patient, the population, then I think we kind of need to step back and say we need to maybe understand what people want so that we can have a good meeting of what's going to work and what's going to fit the needs and lifestyles of our patients. Because these are things they might have to do for many, many years and starting maybe even in their 20s or 30s. So, it makes a difference. Dr. Rafeh Naqash: From what you learned in the study, are you thinking of any subsequent interventional approaches, whether they involve a simple phone call to the patient regularly or perhaps, even though I'm not a big fan of EMR prompts, like an EMR prompt of some sort, where they talk, where they're instructing the provider, whoever is seeing the patient physician or the APP or the geneticist that, “Hey. Did you counsel the patient?” And its sort of a metric how in the oncology side they say, “Well, your metric is you should stage all patients and you should talk about toxicities from a reimbursement standpoint and also from a quality improvement metric standpoint. “Is that something you're thinking of? Dr. Michael J. Hall: 100%. So, when we looked at the barriers, many of the kind of the things that were the strongest predictors of who used aspirin versus who didn't were really patients' perceptions of whether aspirin would cause side effects or whether aspirin would be burdensome to take on a daily basis, also, just how much benefit they thought would come from taking aspirin. So, I think there's, number one, I think an intervention and our next delve into this as an interventional study would be both education about the delta prevention benefit that you get from aspirin, the safety profile of aspirin, which is really quite excellent. And also, I think the data that are so important that in this study by Burn et al, it was actually only two years of intervention that then paid off for 10 years down the line, right? So, I think that's important. The other thing that we actually learned as an aside in this study was actually the kind of intervention that patients wanted the most was actually not a drug and was not a vaccine and was not another kind of special scope to stick somewhere. What they actually were most interested in were interventions related to diet. People really see diet as being an important part of health, or I should say diet and nutrition. And so, I think a subsequent study would perhaps wed both a nutritional intervention of some kind with a chemo prevention in some sort of time limited fashion, so that folks felt like they were both focusing on something that was more important to them, but also, something that was related to the study that we wanted to look at. So that's kind of my idea of where we're going to go in the future with this. Dr. Rafeh Naqash: Excellent. Sounds like the next big RO1 for your group. Dr. Michael J. Hall: Let's hope so. Dr. Rafeh Naqash: Well, I hope the listeners enjoyed talking about the science and learning about aspirin Lynch syndrome. The last couple of minutes are about you as an individual, as an investigator. Can you tell us what your career journey has been like, how you ended up doing what you're doing, and perhaps some advice for early career junior investigators on what this whole space looks like and how you pace yourself and how they can learn from you? Dr. Michael J. Hall: I really got interested in oncology during my residency training. I really found that I really liked oncologists. I found them to be a bit more of a science focused group. They liked research, but you're in oncology because you understand the fears and the challenges of cancer. And so, it's both a combination of that love of science, but also that real human touch of taking care of people. The thing I always tell my fellows as well is the other thing I love about oncology is if you tell people they don't have cancer, they don't want to come back to you. Now, of course, that's modified in the prevention setting. But I really like that when people come to me in my GI oncology clinic, it's because they have a diagnosis and if I say you actually don't have cancer, they go off to their life, and so you're really spending your time on real subjects. The person who really got me most interested in Lynch syndrome and this kind of prevention research was a mentor from University of Chicago, Funmi Olopade, who really has been an enormous mentor for many, many people in the field. Actually, three people in my fellowship class all went on to careers related to genetics and genomics. So, she's been highly influential and continues to mentor me even in my mid-career. I think in terms of pearls or what keeps this interesting for me, I think as much as oncology treatment and new drugs and trials is super exciting, I love being able to step away from that into my genetics and prevention population and kind of focus on treating people in a different format. Patients who are healthy but are worried about cancer because of a family history or carrying a gene or otherwise, and I feel that that's where I can have also an important impact, but on a different level in educating people and helping them understand how genetics works in an understandable and simple way, but also giving them some tools. And one reason for this study, and the reason I study preferences related to prevention is, again, I don't want to just develop something and spend 10, 15 years of my life developing some intervention that everyone looks at and is like, “I don't really want to do that.” I want to really understand what it is that is important to the patients so that we can hopefully work together to develop things that can not only have impact but have impact on a wide scale. Dr. Rafeh Naqash: Awesome. You mentioned Dr. Olopade. I crossed paths with her actually at an international medical graduate community of practice session earlier this year at ASCO where she talked about her journey as an immigrant, talked about how she started, the kind of impact that she's had. It was obvious evident in the picture that she showed with all her mentees who have kind of gone all over the world. So that was very phenomenal. And it's surprising how small of a world we live in. Everybody knows everybody else. Dr. Michael J. Hall: It's crazy. More so than anyone I think I've met in my career; she is really a huge believer in mentorship and spending that extra time with your mentees. And she has been someone who has continued to promote me as an investigator and build me up and get me involved in things. And like I said, I've been in oncology now for quite a few years. But having that person who I think is always thinking about their trainees and people who have learned and grown under them, because what it does is it gives you that fire as well as an investigator to do the same thing for the people that you are a mentor for and train. So, I try to be just as good of a mentor to my genetic counselors and the fellows who come through me and my APPs to give them opportunities to get them excited about research and when they have these big moments to do that. So, yeah, I know Funmi just has had a huge impact on the field of genetics. I still remember some of our early conversations on the wards when she said to me, “Oh, this is such an interesting case. We don't really have anyone who's studying Lynch syndrome so much right now and you should really get into this area.” And I remember thinking, “Okay, I want to develop a niche and here's a niche that's waiting.” Dr. Rafeh Naqash: Clearly it paid off big time and you're paying it forward with your mentees. So, thank you again for joining us. This was an absolute pleasure. Hopefully, the listeners learned a lot about the science and also your journey and how you're trying to impact the field. Thank you for listening to JCO Precision Oncology Conversations. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all ASCO shows at asco.org/podcasts   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 opinion, 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.      

Host Dr. Davide Soldato and Dr. Aaron Mitchell discuss the JCO article "Quality of Treatment Selection for Medicare Beneficiaries With Cancer" TRANSCRIPT Dr. Davide Soldato: Hello and welcome to JCO After Hours, the podcast where we sit down with authors from some of the latest articles published in the Journal of Clinical Oncology. I am your host, Dr. Davide Soldato, medical oncologist at Hospital San Martino in Genoa, Italy. Today, we are joined by JCO author Dr. Aaron Mitchell. Dr. Mitchell is a medical oncologist working at Memorial Sloan Kettering Cancer Center where he is also part of the Department of Epidemiology and Biostatistics. Dr. Mitchell specializes in treating genitourinary malignancy and has a research focus on improving how the healthcare system helps people with these and other cancers. So today, Dr. Mitchell will be discussing the article titled, “Quality of Treatment Selection for Medicare Beneficiaries with Cancer.” Thank you for speaking with us, Dr. Mitchell. Dr. Aaron Mitchell: Well, thank you for inviting me. I'm very glad to be here. Dr. Davide Soldato: So I just wanted to introduce the topic by asking a couple of questions, very general, about the background of the article. So basically you reported the data using the SEER-Medicare to assist to assess the determinants of optimal systemic therapies delivery and selection. So, in particular, you focused on individuals that were diagnosed with cancer who were Medicare beneficiaries and in particular were part of the low income subsidy, which is also known as LIS. So I just wanted to ask you if you could briefly explain to our listeners how this program works, and what was the rationale of the study, and if there is any element of novelty in your study compared to what was done before the study was published. Dr. Aaron Mitchell: Yeah. So that's a lot to cover, but yeah, a lot of opportunity to introduce the low income subsidy program which is a very important part of the Medicare program for prescription drugs, but often one that flies under the radar a little bit in the policy discussion. So this subsidy was created synchronously back with the Medicare Part D Program, which was created in 2006. There was some anticipation that for some high cost drugs, not all patients would be able to afford them even with the Part D program insurance as it was being created. And so they created a pathway to give an additional subsidy to some patients who had low income, who were anticipated to being at need and needing that assistance to afford high cost drugs. As the number of high cost drugs has really risen since 2006, this program has played an important role in helping patients afford drugs, especially those who need very expensive cancer drugs.  And what this program does is, once you meet the eligibility requirements, which require patients to have both quite a low income. So if you're single, that is at 135% of the federal poverty limit or below, and it also places some restrictions on assets. You also have to have low assets, so low income and low assets in order to qualify for the subsidy. But then once you do, the subsidy is really quite large. Patients who qualify for the LIS at the full subsidy level will pay about $10 per month per drug, even for specialty cancer drugs. So if you think about drugs such as those that we use to treat prostate cancer, my specialty, drugs like enzalutamide or XTANDI that run $15,000 to $20,000 per month, the out of pocket cost for a low income subsidy beneficiary is $10. So that is a huge discount. $10 isn't nothing, but even for someone with a low income, if they've got one or two cancer drugs that are at this rate, it's something that they can often afford.  This program applies to Part D cancer drugs that are prescription drugs basically. By and large, these are oral pills that patients are taking on a daily basis at home. These are the drugs that the low income subsidy program applies to. So if a patient needs a drug like that to treat their cancer, then they are able to receive it at very low cost. And what you'll see is a patient- in the studies that have been done, when a patient has low income, low enough for them to be able to qualify for this program, they then have better access to these drugs. You see increased adherence rates, you see increased prescription fill rates. And then when someone, when their income is just high enough to no longer qualify for this program, and they go back to regular Medicare Part D coverage, that's when the problems arise. So it's like as your income moves up the scale, you actually get more problems affording your cancer drugs. So that's the state of the literature so far.  And what we realize though, is that all these studies that have looked at the low income subsidy have really focused on just the Part D drugs themselves, the oral drugs. And that's certainly not all of cancer care. There is a growing number of oral drugs, but for many cancers, especially when you're talking about immunotherapy drugs or new systemic radioligand therapies, these are not Part D drugs, these are Part B drugs. And so even if you are low income and you're qualifying for this subsidy, it's not going to help you if you need a Part B drug. Yes, there are certainly a whole host of other programs and different avenues that we can get patients assistance, but some percentage of them, even though they're low income and high need, would not have assistance with a Part B drug.  So now, in coming back, the long answer to your question, our rationale was, let's look at these Part D low income subsidy patients and let's see what their access looks like, not just to the oral drugs, but to cancer care writ large. And can we study where they're fitting into the system, not only when they need oral drugs, but when they need any kind of cancer care across the board? Dr. Davide Soldato: So basically, just to summarize, it was an extension of previous literature, but specifically evaluating whether novel regimens that use, for example intravenous drugs, they were covered at the same level and whether there were any inequities in access to cancer treatment under this specific program, which is the LIS. Dr. Aaron Mitchell: Yes, I'd say that's a fair summary. Dr. Davide Soldato: Okay. So more or less, you included 9,000 patients inside of the study and 25% of them were beneficiaries of the LIS program. And you specifically looked at factors that could be associated with not receiving therapies at all, and also whether the quality of care that these patients were receiving were any different compared to those who were not part of the LIS program. So I just wanted to see if you could guide us a little bit in the results, whether you see any kind of differences when we look at access to any type of systemic therapies and whether being a part of the LIS program modified access to the drugs. Dr. Aaron Mitchell: Let me take this opportunity also to highlight a feature of our study that differentiates us a little bit from previous work that's been done. And this is around the specific definition of quality that we use. I know quality is in the title of the manuscript, but I think it's important to emphasize exactly what we mean in this study when we say quality, and it's something very specific. So our measure of quality references back to the NCCN guidelines, which I don't think our audience needs much of an introduction to that. It's the most worldwide recognized standard of care guidelines for oncology practice. And we specifically looked not only at the NCCN guidelines, but at their evidence block scoring system. So what we did was we looked not only at one set of guidelines, but we looked at guidelines across time. We looked at guidelines across our full study period, which was, give or take, 2015-2018, depending on the cancer. And we looked at each point in time to see what was the treatment regimen that was recommended by the NCCN guidelines as being preferred. Some of them make that designation, some of them don't. If there was not a designation of preferred, then we turned to the evidence blocks. And the evidence blocks, we then apply several different measures to kind of rank treatments from those that get high scores for efficacy and safety to those that get low scores for efficacy, safety and the quality of evidence. So we basically come up with a kind of a rank list of the recommended treatments at each point in time. And then we look at the ones that are the highest, we say which are the most highly recommended treatments at any given point in time. That then becomes our definition of quality treatment. And I'm saying this with air quotes, we use the term “optimal treatment” in the study. Did they get that treatment? If there were ties, you could have gotten either of the two treatments that got the equally good score, did you get that treatment versus did you get anything else?  So then getting back to our analysis, what we really did was kind of a two-stage study. First, we put all of our patients into our pool, into one big analytic model. And we looked to see what are the factors that predict or are associated with a patient either getting no systemic therapy or any systemic therapy. And then as a second question, we look at the patients who got some form of systemic therapy, and then we ask, again, what percentage of those got the optimal treatment or high quality treatment as opposed to one of the more lowly recommended treatment regimens? So that's how we asked it. We found that patients who were low income subsidy recipients, the low income ones, they were both less likely to receive any systemic therapy. And then even the ones that receive systemic therapy, the ones who made it in the door to see their doctor or their part of the system, they still were less likely to get the optimal treatment that was recommended for their cancer type at the time that they were diagnosed. Dr. Davide Soldato: So basically, even when you are a part of this subsidiary program, you still have a lower access to any type of treatment. And even if you get treatment, you kind of get the ones that were not the preferred according to the NCCN guidelines, or at least they were not scoring as well as those specific regimens. But I think that what our audience might be wondering about is that frequently there are also some other types of characteristics, for example, age or number of comorbidities, which can be associated with having a low socioeconomic status. So I was wondering whether in the analysis you kind of looked specifically also at patient factors, for example, income rather than age or comorbidities, and whether you found any significant association with those and whether it was something that you planned to do in your study. Dr. Aaron Mitchell: Yes. So we looked at many patient factors and those included age and they included the degree of comorbidity. And what we saw with respect to those characteristics was not too surprising. We saw that patients who were older were less likely to receive systemic therapy. We saw that patients who had more comorbidities were also less likely to get systemic therapy. And then across our different designations of treatments, we saw that those patients were also less likely to get the optimal treatment for their cancer. This result though, we would say it certainly needs more study in the future, but it's not immediately concerning. And that is because for patients who have more age, more comorbidity, those often correlate with frailty. And so it could be that these patients aren't getting optimally treated or it could be that their oncologists are just making clinically appropriate decisions about patient selection.  We saw as we were doing this work that the treatment regimens that are often getting the highest recommendations from the NCCN, hence, it would become our definition of high quality optimal treatment, are often ones that are aggressive. They're often ones that are multi-drug combinations. They're often ones that it's not just your old antineoplastics, it's the antineoplastics plus an additional immunotherapy or plus a targeted drug. So it's the ones that are more aggressive by and large, and that might be in some cases more than a patient who is older, more frail, could be able to tolerate. And so the oncologist might be making inappropriate judgment to say I'm going to do something a little bit less aggressive here and make an appropriate trade off between anti cancer efficacy and safety.  I think we've got kind of a bookmark there and we can look at those trends in the future. So we saw that kind of as expected, and then we turned and looked towards the low income subsidy. And our premise there is, well, your income shouldn't predict what you're getting clinically. In an ideal world, you'd be able to get the appropriate treatment for a patient, and not depend on whether their income is above or below 135% of the poverty limit. So that one seems more like on its face an immediate concern. Dr. Davide Soldato: Thank you very much for the explanation. I was just wondering, did you make some kind of selection when you were analyzing specific diseases or settings where you included just metastatic patients or you also included patients with early stage neoadjuvant treatments? Because I think that it is also very interesting from the perspective of the objectives that we have as oncologists when we are administering systemic treatments. Dr. Aaron Mitchell: Yeah, thank you for bringing that up. That was also one of the goals of our study was to be broad. And we wanted to look for factors, whether it be low income subsidy, whether it be age, socioeconomic background, etc., things that would be broad predictors of outcomes, and by which I mean care delivery outcomes across the board. So not just for, let's say, metastatic breast cancer, but also across any cancer that a patient might walk in the door with, what are the systemic predictors. And so when you mentioned before that our overall cohort is approximately 9,000 patients, that's 9,000 patients split over a variety of what we call clinical scenarios or clinical indications. And that includes multiple solid tumor as well as liquid tumor malignancies. It includes both patients who are initiating systemic therapy with palliative intent for metastatic disease. It also includes several groups of patients who are getting adjuvant therapy. So we want it to be as broad as possible. Our selection of those scenarios was really done with the goal of being as broad as possible and really bringing in everything that we could within the constraints of our data source. And that was really the only limitation that we applied in concept was tumor types that are common enough to have a meaningful sample of patients to analyze. So, one, are there enough patients? And then two, are you able to identify this specific group of patients within SEER-Medicare data? Because when the NCCN divides groups of patients by biomarkers that are not available in SEER-Medicare, we can't really say, “Oh, we're going to study this group of patients.” That would then be one that we have to leave on the side and not include. But everything else where one of those things didn't apply, we tried to include it as best we could. Dr. Davide Soldato: Thank you very much for the explanation. And among the scenarios that you included in the study, were there any striking differences in terms of access to treatment and access to quality treatment the way you define the study? Dr. Aaron Mitchell: Yes, there were differences between these different cancer types, these different cancer indications, but they're not differences that I want to over interpret or read too much into. Certainly, every cancer indication is going to be different, but when we start getting into the individual cancer types, the sample size does get smaller. And we've not done formal tests of comparison or heterogeneity among cancer types. So I don't want to say that the differences which we certainly do see, like numerically, there are differences in the proportion of patients who are getting optimal treatment versus no treatment. I don't want to say that it's because the low income subsidy status or patient age has a bigger impact, let's say for lung cancer than breast cancer. I want to say that is heterogeneity for potential future study when we are able to do a similar follow up analysis with say a larger sample size. I don't want to over interpret those differences at the moment. Dr. Davide Soldato: I was just wondering in case there was anything in particular that you wanted to highlight. But in the end, I think that we also have to acknowledge that the data are based on claims data, observational data. So maybe you're right when you say we should not over interpret this type of difference.  And this is just to speculate a little bit, do you think that if you would look at this same specific question in a more contemporary diagnosis frame, like for example, you refer to the fact that most of the diagnoses were between 2016 and 2018. Now that we have more and more of these drugs that would qualify as Part B in the adjuvant or new adjuvant setting, do you think that you would see more differences compared to what you observed in the current study or do you think that it would be more or less the same? Of course this was not part of the analysis that you did, but it's just to have your opinion on the topic in general. Dr. Aaron Mitchell: My expectation would be that since not much has changed with respect to the low income subsidy program from the time period of our study until now, my baseline expectation would be that those results would hold. On the other hand, it is the case that there have been improvements to the standard Medicare Part D benefit since the time of our study. So the low income subsidy patients would be paying the same low out of pocket costs that I mentioned before, about $10 a month give or take, for a specialty cancer drug. But what has started to happen is that for everyone else, their coverage has improved. Because in the US we're in the process of closing, or I think now we finally finished, but you know, a few years lag in claims data, we've closed what used to be called the donut hole, where there was this big coverage gap where patients had to pay a large amount out of pocket for drugs. So there might therefore be a narrowing of the difference, let's say between our low income subsidy participants, the lowest income patients, and then everyone else. But not so much because the low income subsidy status improved or changed, but just because the baseline level of coverage for everyone else may have improved, narrowing that gap. So I'd say that would be very possible.  And if your question is more geared towards not so much policy changes, but treatment landscape changes, I would say the big thing that I would maybe guess, and again, this is very much speculation, but you introduce the speculation in TBD on follow up. I think the big change in the landscape has been the broadening indication and uptake of immunotherapy drugs, our PD-1, PD-L1 inhibitors, for a variety of cancer types. And I think the way that that would manifest in our data, were we to repeat it in a more contemporary data set, would be, I think that the access for, let's say, that any systemic therapy among older patients might change. And that is because rather than just having your cytotoxics in hand, the clinical oncologists now know that for many cases there's if not first line therapy, then second line therapy for patients who don't qualify, you can go straight to it, to someone who's not a chemo candidate, you've got a much more tolerable treatment in your back pocket. And so I think that for patients who are more old or more comorbid, we might start to see that a greater proportion of them receive some systemic therapy, it just might not be the cytotoxic agent that is still most highly recommended. It might be, say a single agent, PD-L1 inhibitor, because their oncologist wants to be able to give them something. So I wouldn't be surprised if that gap starts to narrow as well if you're measuring no systemic therapy versus any systemic therapy. Dr. Davide Soldato: And going back to the policy part of the study that you did, do you think that the results of the study that you published in the JCO can better inform policy makers on how to make these treatments more available and be sure that the largest possible proportion of patients gets a systemic treatment and gets the optimal systemic treatment? Dr. Aaron Mitchell: Yes, I do think that this study has some direct and indirect policy implications. I think that our finding is one to highlight the low income subsidy program and maybe help it not to fly under the radar so much anymore. I think all the work that has been done on how much it has helped patients who need oral cancer medications is great, and it shows how beneficial this program can be. We're now shining the light kind of everywhere else and saying, “Okay. That's great. Here's how well it can work when it covers an oral drug, but we've got this group of low income patients who are still at need and they're still very clearly not able to access everything else. When it's not axitinib that they need, it's a pembrolizumab, they're still very much behind the curve and they need some help.” So I think that's one thing just to call attention to this as an ongoing problem. Low income patients, it's not a solved problem yet. It's something that needs further attention.  And then for direct policy implications that are on the table, I think we're about to see the Medicare program be able to start negotiating not just Part D drugs, but also in future years, Part B covered drugs and try to lower the price for everyone, both for insurance, both for Medicare itself. And then to the extent that that boils over to the patient's out of pocket responsibility, it'll start to reduce the patient out of pocket costs as well. So I think we can look forward to hopefully an aggressive negotiation program by Medicare to start to directly lower the prices of Part B cancer drugs that these patients are unable to afford. Dr. Davide Soldato: Thank you very much. You did the research you published in the JCO, but you really seem very passionate about the topic of care delivery and quality of care and policy. So I just wanted to ask on a personal note, how did you come to this area of research which is frequently not one that is very cared for by oncologists? It's more frequently something that biostatisticians or public health scientists put their attention to. I just had this curiosity and I wanted to ask you if you could explain a little bit how you came to this area of research. Dr. Aaron Mitchell: Thank you for asking. That's a great question. I'll tell my favorite story about my journey there. I entered medical school planning to be a clinical investigator or maybe even a basic science researcher, and I had some background in that. I went to medical school at NYU where the teaching hospital is Bellevue, which is a large, well known public hospital within New York City. And my eyes started to open regarding the inequities in the system. You always hear about it, you read about the problems in the US healthcare system, but then when you see it on a day to day basis and you can walk four blocks from a private, very well resourced hospital to see a patient with a similar condition four blocks down the road at a under resourced public hospital getting very different treatments and receiving very different outcomes, the injustice in the system really hits you on a visceral level. And it was really, I would say, as soon as I started my clinical rotations in medical school that I realized maybe that's where I can make the most impact with my career and just really fell into it. By the time I was done with medical school, I then knew that I wanted to do something that was in the health policy space. And then by the time I was done with residency, I was like, “Oh, someone had mentioned the words health services research” and the light went on. It's like, “Oh, that's me. That's what I want to do.” Dr. Davide Soldato: Thank you very much. That was a nice story. And I really think that we should all work towards trying to make sure that the inequities inside of the system are eliminated as much as possible.  So I think that this concludes our interview for today. So thank you again, Dr. Mitchell, for joining us. Dr. Aaron Mitchell: You're very welcome and thank you so much for your interest. Dr. Davide Soldato: We appreciate you sharing more on your JCO article titled, “Quality of Treatment Selection for Medicare Beneficiaries with Cancer.”  If you enjoy our show, please leave us a rating and review and be sure to come back for another episode. You can find all ASCO shows at asco.org/podcasts.   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 opinion, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.

In today's episode, we had the pleasure of speaking with Alan P. Venook, MD, about recent updates to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for gastrointestinal (GI) cancers. Dr Venook holds the Madden Family Distinguished Professorship in Medical Oncology and Translational Research and is a professor in the Department of Medicine (Hematology/Oncology) at the University of California San Francisco (UCSF). He is also the Shorenstein Associate Director for Program Development at the UCSF Helen Diller Family Comprehensive Cancer Center.

Throughout the history of cancer advocacy, there are the advocates who made us and the organizations who made us. And one such organization is the National Comprehensive Cancer Network, which is — for all intents and purposes — the “Good Housekeeping meets Consumer Reports” of all cancer standards of care, best practices, guidelines, and credibility consensus. Joining me on today's show to speak to all that is my friend Marcie Reeder, Executive Director of the NCCN Foundation, which is their patient-friendly arm that collaborates with scores of nonprofits to make sure their information is trickled down to the patient and caregiver community as a vital support resource. Marcie lost her father to esophageal cancer when she was young. Her public service to advance the narrative and the imperative of access, awareness, and survivorship is a testimony to her passion, character, and the very definition of cancer advocacy. NCCN is an incredible organization that does outstanding work on behalf of millions of people, and I hope this episode shines a light on their impact on the cancer community. Enjoy the show.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.