Podcasts about transcript dr

Dr. John Sweetenham shares highlights from Day 3 of the 2025 ASCO Annual Meeting, including new research for the treatment of advanced renal cell carcinoma and 2 studies on novel approaches in non-small cell lung cancer. Transcript Dr. John Sweetenham: Hello, I'm Dr. John Sweetenham, the host of the ASCO Daily News Podcast, with my takeaways on selected abstracts from Day 3 of the 2025 ASCO Annual Meeting. Today's selection features studies addressing the treatment of advanced renal cell carcinoma and 2 studies exploring novel approaches in non-small cell lung cancer. My disclosures are available in the transcript of this episode. The first abstract is number 4505. This study, led by Dr. Toni Choueiri of the Dana-Farber Cancer Institute, describes the final analysis of the CheckMate 214 trial, which compared the combination of nivolumab and ipilimumab with sunitinib for the first-line treatment of advanced renal cell carcinoma. The ipi-nivo combination is approved for the frontline treatment of intermediate and poor-risk advanced renal cell carcinoma based on the primary analysis of the CheckMate 214 trial, which demonstrated a higher response rate and longer overall survival compared with sunitinib. Today's presentation provided the final safety and efficacy results for the trial with long-term follow-up of more than 9 years.  The intent-to-treat (ITT) population in this trial comprised 550 patients randomized to nivo and ipi versus 546 who received sunitinib. The final analysis showed sustained long-term benefit for the combination therapy. Patients given nivolumab plus ipi had a 29% reduction in the risk for death compared with sunitinib. For patients with intermediate or poor-risk disease, there was a 31% reduction in the risk of death.   The probability of remaining in response through 8 years was more than doubled with nivolumab plus ipilimumab versus sunitinib in the ITT population at 48% versus 19%, and in the intermediate and poor-risk population at 50% versus 23%. The other important observation is that patients with favorable-risk disease appeared to have a 20% reduction in the risk for death at 9 years and more durable responses. This suggests a possible delayed benefit for ipi and nivo in this group since these differences were not seen in the earlier analysis.   No new safety signals emerged with longer follow-up, and the results confirm the use of ipi and nivo as a standard front-line combination therapy in this disease. Since this combination has been in widespread use for some years, the results are not surprising although the subgroup analysis suggesting benefit in favorable-risk patients is likely to inform practice in the future.   Today's second abstract is number is 8506, which was presented by Dr. Tony Mok from the Chinese University of Hong Kong, describing results from the phase 3 HERTHENA-Lung02 trial. This trial compared the antibody-drug conjugate patritumab deruxtecan with platinum-based chemotherapy in patients with EGFR-mutated advanced non-small cell lung cancer following a third-generation tyrosine kinase inhibitor (TKI).  Patritumab deruxtecan, also known as HER3-DXd, comprises a fully human anti-HER3 IgG3 monoclonal antibody conjugated to a topoisomerase 1 inhibitor payload, and showed activity in a previous phase 2 trial in patients relapsing after EGFR TKI and chemotherapy.   In this phase 3 study, this agent was compared with platinum-based chemotherapy in eligible patients with an EGFR-activating mutation who had previously received 1 or 2 EGFR TKIs, at least one of which was a third-generation drug, with relapse or progression after this therapy. Five hundred and eighty-six patients were enrolled, with progression-free survival as the primary endpoint.  The primary analysis showed a 9-month progression-free survival of 29% for the experimental arm compared with 19% for platinum-based chemotherapy, for a hazard ratio of 0.77 and a P value of 0.011. With higher progression-free survival rates at 6 months and 12 months, HER3-DXd also had a better objective response rate (35.2% versus 25.3%) compared with platinum-based chemotherapy (PBC), and HER3-DXd also extended intracranial progression-free survival compared with PBC in patients with brain metastases, with a hazard ratio of 0.75. Grade 3 or more treatment-related adverse events occurred in 73% of patients treated with HER3-DXd and 57% of patients who received PBC. HER3-DXd had a higher rate of grade or more 3 thrombocytopenia, and drug-related interstitial lung disease occurred in 5% of patients in the HER3-DXd arm.   The follow-up will need more time to mature since no overall survival data are currently available, but definitely an agent to watch with interest. Moving on to today's final abstract, 8500, was presented by Dr. Pasi Jänne from the Dana-Farber Cancer Institute, describing results from the phase 2 portion of the KRYSTAL-7 study. This study is exploring the use of a potent KRAS inhibitor, adagrasib, in combination with pembrolizumab in patients with advanced or metastatic KRASG12C- mutated non-small cell lung cancer.  Adagrasib has already received accelerated approval in the U.S. for previously treated locally advanced or metastatic NSCLC with a KRASG12C mutation. A previous report from the KRYSTAL-7 study demonstrated encouraging activity in combination with pembrolizumab in the frontline setting for this patient group who also had more than 50% expression of PD-L1. The presentation today described efficacy and safety data for this drug combination across all PD-L1 expression levels.  One hundred and forty-nine patients with a median age of 67 years were treated with the combination, 104 of whom had PD-L1 expression level results available, representing the so-called biomarker population in this trial. The overall response rate for the entire study population was 44%. In the biomarker population, the overall response rate ranged from 36% in those with less than 1% PD-L1 expression to 61% for those with more than 50% expression. For all patients, the median response duration was just over 26 months, and the median progression-free and overall survival rates were 11 and 18.3 months respectively.    For the biomarker population, the median progression-free and overall survival were highest in those patients with more than 50% PD-L1. No new safety issues emerged from this analysis; the most frequent toxicities were nausea, diarrhea, and increases in transaminases. Immune-related toxicities included pneumonitis, hypothyroidism, and hepatitis. These are important results and the results of the phase 3 portion of KRYSTAL-7, which compares first-line therapy with adagrasib plus pembro versus pembro alone in the KRASG12C mutated/PD-L1 more than 50% group, will be informative. For those patients with lower levels of PD-L1 expression, the authors suggest that the treatment escalation may be beneficial, possibly including the addition of chemotherapy.  That concludes today's report. Thanks for listening and I hope you will join me again tomorrow to hear more top takeaways from ASCO25. If you value the insights that you hear on the ASCO Daily News Podcast, please remember 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 speaker:    Dr. John Sweetenham    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. John Sweetenham shares highlights from Day 2 of the 2025 ASCO Annual Meeting, including new data on the treatment of ER+/HER2-negative breast cancer and potentially practice-changing results for patients with cutaneous squamous cell carcinoma at high risk of recurrence.  Transcript Dr. John Sweetenham: Hello, I'm Dr. John Sweetenham, your host of the ASCO Daily News Podcast, welcoming you to our special coverage of the 2025 ASCO Annual Meeting. Today, I'll be bringing you my takeaways on selected abstracts from Day 2 of the Meeting. My disclosures are available in the transcript of this episode.  Today's selection features important, new data on the treatment of ER-positive, HER2-negative breast cancer, the use of tumor treating fields in combination with chemotherapy for locally advanced pancreatic cancer, and potentially practice-changing results for patients with cutaneous squamous cell carcinoma at high-risk of recurrence.  Our first selected abstract is LBA1000. This important phase 3 study was presented by Dr. Erika Hamilton from the Sarah Cannon Research Institute in Nashville and evaluated the use of a novel agent, vepdegestrant, in patients with ER-positive/HER2-negative breast cancer, which had progressed after first-line endocrine therapy. Vepdegestrant is a selective oral PROTAC estrogen receptor degrader, which targets wild-type and mutant estrogen receptor through a novel mechanism of action which directly harnesses the ubiquitin-proteasome system to degrade ER. It has potential advantages over fulvestrant, a selective ER degrader which has to be administered intramuscularly and has limited benefit in patients who progress after endocrine therapy plus a CDK4/6 inhibitor.  Building on the encouraging results from the initial phase 1/2 study of vepdegestrant, Dr. Hamilton reported results from the VERITAC-2 global phase 3 trial, comparing this agent with fulvestrant. The patients in the study had already received treatment with hormone therapy and a CDK inhibitor and were randomly assigned to receive treatment with either vepdegestrant (313 patients) or fulvestrant (311 patients). The vepdegestrant was taken orally each day, while the fulvestrant was given intramuscularly on days 1 and 15 of the first cycle of treatment and day 1 of each subsequent treatment cycle. Patients were stratified by the presence of wild-type ER or ESR1 mutation. A total of 43.3% of patients had ESR1 mutations; 136 of those were in the vepdegestrant group and 134 in the fulvestrant group.   For patients with ESR1 mutations, vepdegestrant significantly increased progression-free survival compared with fulvestrant. For patients who received vepdegestrant, the median PFS was 5 months versus 2.1 months for those who received fulvestrant. The clinical benefit rate was 42.1% in the vepdegestrant group vs. 20.2% in the fulvestrant group. The overall response rate was 18.6% in the vepdegestrant group compared with only 4% in the fulvestrant group.  The PFS and response benefits of vepdegestrant were largely restricted to the population with ESR1 mutations. Overall survival data are currently immature. The safety profile was favorable, with fewer than 5% of patients having dose reductions or discontinuation due to toxicity. The most frequent toxicities were fatigue, nausea, and elevated transaminases.  The authors concluded that oral vepdegestrant demonstrates statistically significant and clinically meaningful improvement in progression-free survival compared with fulvestrant in this group of patients with ESR1-mutated ER+/HER2- advanced breast cancer who have progressed after endocrine therapy and a CDK inhibitor. Patients with recurrent disease in this context are now routinely tested for ESR1 mutations, and this agent is for sure a potential treatment option for them.  The next study on today's episode, LBA4005, reports on the use of tumor treatment fields for patients with locally advanced pancreatic cancer. Tumor treatment fields are electric fields which disrupt cell division and may also induce an enhanced immune response, using a non-invasive portable device attached to the skin, and are already approved for the treatment of some cancers, including GBM and non-small cell lung cancer. A previous phase 2 trial, PANOVA-2, confirmed the feasibility and safety of using this approach in combination with gemcitabine plus or minus nabpaclitaxel in pancreatic cancer. In today's presentation, Dr. Vincent Picozzi from the Virginia Mason Medical Center in Seattle presented the results of the PANOVA-3 trial, a phase 3 study comparing gemcitabine and nabpaclitaxel with the same chemotherapy plus tumor treatment fields in patients with locally advanced pancreatic adenocarcinoma.  Five hundred and seventy-one eligible patients were enrolled in the study with a total of 405 (198 in the treatment field group and 207 in the standard arm) comprising the modified intent- to-treat population. The duration of chemotherapy treatment was comparable in both study arms, and patients receiving treatment fields had a median exposure of almost 27 weeks.  Statistically significant improvements were observed for several study endpoints, including overall survival (a median of 16.2 versus 14.2 months), distant PFS (at 13.9 versus 11.5 months) and pain-free survival (at 15.2 versus 9.1 months), all in favor of the treatment fields arm. Although quality of life data were not reported in detail, the authors noted a significant improvement in global health status in the treatment fields arm. Safety data showed a higher level of skin adverse events in the treatment fields arm but were otherwise as expected for the GnP combination.  These are quite remarkable results which add to the growing evidence base for tumor treatment fields and are particularly compelling in this patient group given the substantial improvement in pain-free survival. It will be especially interesting to see the mature analysis of the quality-of-life endpoints in a subsequent report.  The final selection today is Abstract 6001, which describes the C-POST trial, a phase 3 trial of adjuvant cemiplimab versus placebo in patients with high-risk cutaneous squamous cell carcinoma of the skin. This study was presented by Dr. Danny Rischin from the Peter MacCallum Cancer Centre in Melbourne, Australia.   Although surgical resection with or without adjuvant radiation is curative in 90% of patients with cutaneous squamous cell carcinoma, high-risk features, including nodal disease, skin and subcutaneous metastases, perineural invasion and bone involvement, predict for an inferior prognosis.  Cemiplimab, a PD-1 targeting antibody is standard therapy for patients with locally advanced or metastatic disease who are not candidates for curative surgical resection or radiation therapy, with an overall response rate of almost 50%.  The C-POST study evaluated the use of cemiplimab as adjuvant therapy following surgery and radiation in high-risk patients, compared with placebo. Treatment was administered at 3-week intervals for 12 weeks, and then 6-week intervals for a further 36 weeks, with a primary endpoint of disease-free survival. Four hundred and fifteen patients were randomized in the study, 209 to cemiplimab and 206 to placebo. With median follow-up at 24 months, Dr. Rischin reported a highly significant improvement in disease-free survival for the cemiplimab arm, 49.4 months for placebo versus not reached for cemiplimab, with improvements also observed in the rates of locoregional recurrence and distant recurrence at 80% and 60% reductions, respectively. No new safety signals were observed.  This study is potentially practice-changing and provides strong evidence that cemiplimab should be considered the new standard of care in this clinical context.  Thanks for listening today and join me again tomorrow to hear more top takeaways from ASCO25. If you value the insights that you hear on the ASCO Daily News Podcast, please remember 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 speaker:   Dr. John Sweetenham   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  

In the first episode of a special daily series during the 2025 ASCO Annual Meeting, Dr. John Sweetenham discusses the results of 2 studies on the treatment of advanced colorectal cancer plus an additional study exploring the association of Medicaid expansion with cancer survival outcomes. Transcript Dr. John Sweetenham: Hello, and welcome to our special coverage of the 2025 ASCO Annual Meeting on the ASCO Daily News Podcast. I'm your host, Dr. John Sweetenham, and I'll be bringing you brief analysis on selected abstracts from each day of the Meeting. My disclosures are available in the transcript of this episode.  Today, I'll be reviewing three abstracts, the first two of which address the treatment of advanced colorectal cancer. Today's first study is Abstract 3501. These data were presented by Dr. Heinz-Josef Lenz from the USC Norris Comprehensive Cancer Center and report on the expanded analysis of the CheckMate-8HW trial. This was a phase 3, international, multicenter trial in patients with MSI-high/MMR-deficient metastatic colorectal cancer, who were randomized between nivolumab (nivo) alone, nivolumab plus ipilumomab (ipi) or investigators' choice of chemotherapy (FOLFOX or FOLFIRI) with or without bevacizumab or cetuximab. The study showed that nivo plus ipi demonstrated superior progression-free survival compared with chemotherapy in the first-line setting and superior progression-free survival compared with nivo alone across all lines of therapy. These results led to the approval of nivo + ipi in the first-line setting in patients with MSI-H/dMMR mCRC in the U.S., the EU, and many other countries.  In today's presentation, Dr. Lenz reported on the expanded analyses of nivo plus ipi versus nivo across all lines of therapy and longer follow-up results for nivo and ipi versus chemo in the first-line setting. With longer follow up (the median is now at 47 months) nivo and ipi continued to show progression-free survival benefit compared with chemotherapy with a median PFS of 54.1 months versus 5.9 months, for a hazard ratio of 0.21.  Additionally, the analysis of the effects on PFS2, defined as the time from randomization to progression after subsequent systemic therapy, start of second subsequent systemic therapy, or death, showed that compared with chemotherapy, first-line nivo and ipi was associated with a 72% reduction in the risk of death or disease progression, despite the fact that 71% of those who progressed following chemotherapy crossed over to receive subsequent immunotherapy. The study also showed that across all lines, nivo and ipi demonstrated superior progression-free survival compared with nivo alone, the median not reached versus 39.3 months, for a hazard ratio of 0.62. No new toxicity signals emerged after further analysis. Most treatment-related adverse events with possible immune etiology were observed within the first six months of therapy. The results for PFS2 are particularly significant. Up to now, there has been some reluctance to use nivo and ipi as first-line therapy, partly because of its toxicity profile and based on the rationale that it would be active after other frontline therapies. The observation in this study that the beneficial effects of nivo and ipi are maintained downstream is compelling. The results suggest that delaying the use of this combination to the second line or later may compromise subsequent PFS and supports the use of nivo and ipi as a standard-of-care frontline option for MSI-H/dMMR metastatic colorectal cancer. Moving on, the next study I'm featuring today is Abstract 3503, presented by Dr. Jeanne Tie from the Peter MacCallum Cancer Centre and the Walter and Eliza Hall Medical Institute of Medical Research from Melbourne, Australia. This study reported the impact of circulating tumor DNA (ctDNA)-guided adjuvant chemotherapy escalation in stage III colon cancer, focused on the primary analysis of the ctDNA-positive cohort from the randomized DYNAMIC-III trial. As background, about 30% of patients with stage III colon cancer will recur following standard-of-care adjuvant therapy with oxaliplatin-based regimens. And current data show that for those patients with high-risk disease, 6 months of chemotherapy is associated with a lower recurrence rate than 3 months. Circulating tumor DNA following initial surgery has been shown to be a strong independent prognostic factor for these patients, but questions remain about how ctDNA can be used for adaptation of treatment. Questions regarding treatment adaptation were addressed in the DYNAMIC-III trials – specifically, does treatment escalation benefit those who are ctDNA positive following surgery, and can therapy be de-escalated for those who are ctDNA negative. The first of these 2 questions – treatment escalation in the positive group – is the subject of this report. One thousand and two patients were randomized in this study, between ctDNA-informed therapy (502) or standard management (500). Of those patients included in the intent to treat cohorts, 129 were ctDNA positive in the ctDNA-informed arm compared with 130 in the standard management arm. Various pre-planned treatment escalation protocols were used, depending on the choice of first-line therapy. With a median follow up of 42.2 months, there was no difference in 3-year relapse free survival between the ctDNA informed group (48%) and the standard management group (52%). There was, however, a highly significant difference in relapse-free survival for patients who cleared ctDNA by the end of treatment compared with those who didn't. The authors concluded that the recurrence risk for this group remains high, at about 50%, after adjuvant therapy and that it increases with higher ctDNA burden, but treatment escalation didn't appear to reduce the recurrence risk. Clearance of ctDNA was associated with a favorable outcome, suggesting that as more effective treatments are developed in the future for this group, ctDNA will likely prove to have major utility. Changing gears now, my final selection for today is Abstract 11006, presented by Dr. Elizabeth Shafer from the American Cancer Society. This study explored the association of Medicaid expansion with 5-year survival after a cancer diagnosis.  Dr. Schafer began her presentation by providing some historical perspective on the impact of the Affordable Care Act on reducing the number of uninsured adults aged less than 65 years in the United States. She then reviewed some recent data on the impact of Medicaid expansion on cancer care, including improved screening rates, improved access to cancer surgery, and an increase in earlier cancer diagnosis. The current study builds on earlier data from the American Cancer Society which showed improved 2-year overall survival for patients with newly diagnosed cancer following Medicaid expansion. The new study reported by Dr. Schafer examined 5-year cause-specific survival in individuals with cancer since Medicaid expansion, analyzed according to cancer type and various demographic and social factors. Using data from more than 813,000 individuals from 26 states that expanded Medicaid compared with more than 610,000 from 12 states that did not, the authors reported that similar improvements in 5-year cause-specific survival were observed in the expansion and the non-expansion states, but when analyzed by other factors, differences in outcome emerged. For example, although similar improvements in survival between expansion and non-expansion states were seen in urban communities, there was a significant improvement of 2.55 percentage points in survival for individuals in rural communities in expansion states compared with those in non-expansion states. Similar trends were observed in high poverty areas, where improvements in survival were superior in expansion versus non-expansion states.  When examined by cancer type, the authors observed greater improvements in 5-year survival for those with pancreatic, lung, and colorectal cancer, possibly due to improvements in screening and early access to treatment.  The authors concluded that those residing in rural and high-poverty areas experienced the most improvement in cause-specific cancer survival following Medicaid expansion. In summary, it's encouraging to see an improving trend in cancer mortality overall, independent of Medicaid expansion, but it's also important to remember that this is yet another study which confirms how implementation of the ACA has improved cancer outcomes and begun to address some of the disparities in cancer care. Join me again tomorrow to hear more top takeaways from ASCO25. And if you value the insights that you hear on the ASCO Daily News Podcast, please remember 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 speaker:  Dr. John Sweetenham    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. John Sweetenham and Dr. Erika Hamilton discuss top abstracts that will be presented at the 2025 ASCO Annual Meeting, including research on tech innovations that could shape the future of oncology. Transcript Dr. John Sweetenham: Hello, and welcome to the ASCO Daily News Podcast. I'm your host, Dr. John Sweetenham, and I'm delighted to be joined today by Dr. Erika Hamilton, a medical oncologist and director of breast cancer and gynecologic cancer research at the Sarah Cannon Research Institute in Nashville, Tennessee. Dr. Hamilton is also the chair of the 2025 ASCO Annual Meeting Scientific Program, and she's here to tell us about some of the key abstracts, hot topics, and novel approaches in cancer care that will be featured at this year's Annual Meeting. Our full disclosures are available in the transcript of this episode. Dr. Hamilton, it's great to have you on the podcast today, and thanks so much for being here. Dr. Erika Hamilton: Thanks, Dr. Sweetenham. I'm glad to be here. Dr. John Sweetenham: Dr. Hamilton, the Presidential Theme of the Annual Meeting this year is ‘Driving Knowledge to Action: Building a Better Future,' and that's reflected in many of the sessions that will focus on action-oriented guidance to improve care for our patients. And as always, there'll be great presentations on practice-changing abstracts that will change treatment paradigms and transform care. Can you tell us about some of the hot topics this year and what you're particularly excited about? Dr. Erika Hamilton: You're right. Dr. Robin Zon's theme is ‘Driving Knowledge to Action: Building a Better Future,' and you're going to see that theme really interlaced throughout the ASCO program this year. We had a record number of submissions. Over 5,000 abstracts will be published, and there'll be about 3,000 presentations, either in oral format or poster presentations. We have 200 dynamic sessions. Many of the discussants will be highlighting key takeaways and how we can translate action-oriented guidance to better treat our patients to build a better future. Our state-of-the-art science will include a Plenary Session. This will feature presentations as well as discussion of each of the presentations for clinical late-breaking abstracts. We have Clinical Science Symposia that I'm particularly excited about this year. These will feature key abstracts as well as discussions and a foundational talk around the subject. We're covering novel antibody-drug conjugate targets, turning “cold” tumors “hot” to include CAR T, as well as the future of cancer detection. There'll be rapid oral abstracts, case-based panels, and this will also feature interactive audience polling and case discussions. I also want to highlight the community connection opportunities. There will be 13 Communities of Practice that will be meeting on-site during ASCO, and there's also really a plethora of networking opportunities for trainees and early-career professionals, a Women's Networking Center, a patient advocate space, and I'm happy to report there will also be live music out on the terrace this year at ASCO. Dr. John Sweetenham: Well, that's going to be a really great addition. I have to say, I think this is always a special time of year because excitement starts to mount as the meeting gets closer and closer. And once the abstracts are out there, I certainly personally feel that the excitement builds. Talking of abstracts, let's dive into some of the key abstracts for this year's meeting. I'd like to start out by asking you about Abstract 505. This reports on 15-year outcomes for women with premenopausal hormone receptor-positive early breast cancer in the SOFT and TEXT trials. It assesses the benefits of adjuvant exemestane and ovarian function suppression or tamoxifen and ovarian function suppression. So, could you talk us through this and tell us what you think the key takeaways from this abstract are? Dr. Erika Hamilton: Absolutely. This is essentially the SOFT and TEXT trials. They are trials that we've been following for quite some time, evidenced by the 15-year outcome. And I think it really answers two very important questions for us regarding adjuvant endocrine therapy for patients that are facing hormone receptor-positive disease. The benefit of ovarian function suppression for one, and then second, the benefit of exemestane over tamoxifen, which is our SERM [selective estrogen receptor modulator]. So, in terms of the SOFT trial, when we talk about distance recurrence-free interval, which I really think is probably the most meaningful because secondary cancers, et cetera, are not really what we're getting at here. But in terms of distant recurrence-free interval, certainly with tamoxifen, using tamoxifen plus ovarian function suppression adds a little bit. But where we really get additional benefits are by moving to exemestane, an aromatase inhibitor with the ovarian function suppression. So, for example, in SOFT, for distant recurrence-free interval for patients that have received prior chemotherapy, the distance recurrence-free interval was 73.5% with tamoxifen, bumped up just a tiny bit to 73.8% with ovarian function suppression. But when we used both ovarian function suppression and switched to that aromatase inhibitor, we're now talking about 77.6%. It may seem like these are small numbers, but when we talk about an absolute benefit of 4%, these are the type of decisions that we decide whether to offer chemotherapy based on. So, really just optimizing endocrine therapy really can provide additional benefits for these patients. Just briefly, when we turn to TEXT, similarly, when we look at distance recurrence-free interval for our patients that are at highest risk and receive chemotherapy, tamoxifen and ovarian function suppression, 79%; 81% with exemestane and ovarian function suppression. And when we talk about our patients that did not receive chemotherapy, it increased from 91.6% up to 94.6%—very similar that 3% to 4% number. So, I think that this is just very important information when counseling our patients about the decisions that they're going to make for themselves in the adjuvant setting and how much we want to optimize endocrine therapy. Dr. John Sweetenham: Thanks so much for your insight into that. Dr. Erika Hamilton: Yeah, absolutely. So, let's turn to hematologic malignancies. Abstract 6506 reports exciting results on the new agent ziftomenib in relapsed/refractory NPM1-mutant acute myeloid leukemia. This is a phase 1b clinical activity study and safety results. This was the pivotal KOMET-001 study. And my question is, will this new agent fulfill an unmet need in this NPM1 space? Dr. John Sweetenham: Yeah, great question. And I think the answer is almost certainly ‘yes'. So, just as some brief background, NPM1 mutation is known to be a driver of leukemogenesis in around 30% of patients with AML, and it's a poor prognostic factor. And typically, about 50% of these patients will relapse within a year of their first-line therapy, and only around 10% of them will get a subsequent complete remission with salvage therapy. Menin inhibitors, which disrupt the interaction between menin and KMT2A, are known to be active in NPM1-mutated as well as in KMT2A-rearranged AML. And ziftomenib is a selective oral menin inhibitor, which in this study was evaluated at a dose of 600 mg once a day, as you mentioned, a phase 1b/2 study, which is multicenter and presented by Dr. Eunice Wang from Roswell Park. It's a relatively large study of 112 patients who were treated with this standard dose with relatively short median follow-up at this time. The median age was 69 years, and median prior therapies were two, but with a range of one to seven. And I think very importantly, 60% of these patients had previously been treated with venetoclax, and 23% of them had had a prior transplant. Looking at the results overall for this study, the overall response rate was 35%, which is actually quite impressive. Specifically for those patients in the phase 2 part of the study, around 23% achieved a CR [complete remission] or CRh [complete remission with partial hematologic recovery]. What's very interesting in my mind is that the response rates were comparable in venetoclax-naive and venetoclax-exposed patients. And the drug was very well tolerated, with only 3% of patients having to discontinue because of treatment-related adverse events. And I think the authors appropriately conclude that, first of all, the phase 2 primary endpoint in the study was met, and that ziftomenib achieved deep and durable responses in relapsed and refractory NPM1-mutated AML, regardless of prior venetoclax, with good tolerance of the drug. And so, I think putting all of this together, undoubtedly, these data do support the potential use of this agent as monotherapy and as a new option for those patients who have relapsed or refractory NPM1-mutated acute myeloid leukemia. So, let's move on a little bit more now and change the subject and change gears completely and talk about circulating tumor DNA [ctDNA]. This has been a hot topic over a number of years now, and at this year's meeting, there are quite a few impactful studies on the use of ctDNA. We have time to focus on just one of these, and I wanted to get your thoughts on Abstract 4503. This is from the NIAGARA trial, which looks at ctDNA in patients with muscle-invasive bladder cancer who receive perioperative durvalumab. Could you tell us a little bit about this study? Dr. Erika Hamilton: So, this was the phase 3 NIAGARA trial, and this is literally looking for patients with muscle-invasive bladder cancer that are cisplatin-eligible, and the addition of durvalumab to neoadjuvant chemotherapy. So here, this is a planned exploratory analysis of ctDNA and the association with clinical outcomes from NIAGARA. So, this is really the type of study that helps us determine which of our patients are more likely to have a good outcome and which of our patients are more likely not to. There were 1,000 randomized patients in this study, and 462 comprised the biomarker-evaluable population. There were about half in the control arm and half in the durvalumab arm. And overall, the ctDNA-positive rate at baseline was about 57%, or a little over half, and that had decreased to about 22% after neoadjuvant treatment. ctDNA clearance rates from baseline to pre-radical cystectomy was about 41% among those with durvalumab and 31% among those in control. And the non-pCR rate was 97% among patients with pre-cystectomy ctDNA-positive status. So, this really gives us some information about predicting who is going to have better outcomes here. We did see a disease-free survival benefit with perioperative durvalumab, and this was observed in post-cystectomy ctDNA-positive as well as the ctDNA-negative groups. Shifting gears now to GI cancer, Abstract 3506 is a long-term safety and efficacy study of sotorasib plus panitumumab and FOLFIRI for previously treated KRAS G12C-mutated metastatic colorectal cancer. And this is the CodeBreaK-101 study. What are your thoughts on this study? Dr. John Sweetenham: Yeah, thanks. A very interesting study, and this abstract builds upon the phase 3 CodeBreaK-300 trial, which I think has just been published in the Journal of Clinical Oncology. This showed that the combination of sotorasib and panitumumab improved clinical outcomes in patients with chemorefractory KRAS G12C-mutated metastatic colorectal cancer. The current abstract, as you mentioned, reports the CodeBreaK-101 trial. And this was a phase 1b trial where FOLFIRI therapy was added to sotorasib and panitumumab in previously treated patients with KRAS G12C-mutated metastatic colorectal cancer. The abstract reports the overall and progression-free survival results, as well as some updated safety and response data. So, in this study, patients with this particular mutation who had received at least one prior systemic treatment but were KRAS G12C inhibitor-naive were enrolled into an expansion cohort of the CodeBreaK-101 protocol. And these patients received what apparently now recommended as the standard phase 2 dose of sotorasib of 960 mg daily, plus panitumumab and a standard dose of FOLFIRI. And the primary endpoint of the study was safety, and secondary endpoints included confirmed response, overall response, and progression-free survival, as assessed by the investigator. And by November of last year, 40 patients had been enrolled into this study. Common treatment-related adverse events were cutaneous; some patients developed neutropenia, and stomatitis was fairly widespread. Discontinuation of sotorasib because of adverse events was only seen in 1% of patients, although patients did have to discontinue because of toxicity from some of the other agents in the combination. Looking at the results of this study, the updated objective response rate was 57.5%, and the disease control rate was estimated at 92%, going on 93%, with a median time to response of 1.6 months and a median response duration of 6 months. After a median follow-up of 29.2 months, the median progression-free survival was 8.2 months, and the overall survival 17.9 months. So, the authors have concluded that this combination, including sotorasib, panitumumab, and FOLFIRI, does appear to show quite promising long-term efficacy in pretreated patients with this specific mutation. The ongoing phase 3 study they mentioned, CodeBreaK-301, is aiming to evaluate this combination against the standard of care in the first-line setting for patients with KRAS G12C-mutated colorectal cancer. So, promising results, and we'd be very interested to see how this particular combination performs in the frontline. Dr. Erika Hamilton: Fantastic. Thanks so much for sharing that. Let's shift gears again and really talk about digital technology. I feel that we're all going to have to get much better with this, and really, there are a lot of promises for our patients coming here. There are a lot of abstracts at ASCO that are focusing on innovations in digital technology, including a really interesting psychosocial digital application for caregivers of patients that are undergoing hematopoietic stem cell transplantation. Can you tell us a little bit about this? It's Abstract 11000. Dr. John Sweetenham: Yeah, absolutely. This abstract certainly caught my eye, and I think it's intriguing for a number of reasons, partly because it's app-based, and partly also because it specifically addresses caregiver burden and caregiver needs in the oncology setting, which I think is especially important. And although the context, the clinical context of this study, is hematopoietic stem cell transplantation, I think it has potential applications way beyond that. We all know that caregivers of patients undergoing stem cell transplantation have significant quality-of-life struggles. They are well-documented to have significant psychological and emotional strain before, during, and after stem cell transplantation. And this abstract describes an application called BMT-CARE, which is aimed at improving caregivers' quality of life, caregiver burden, mood symptoms, and coping skills, and so on. So, this was a single-center, randomized trial from MGH [Massachusetts General Hospital] of this app for stem cell transplant caregivers, compared with usual care in those individuals. And the eligible patients, or eligible individuals, were adults caring for patients with heme malignancy undergoing either an autologous or an allogeneic stem cell transplant. Patients were randomly assigned either to use the app or for usual care. And the app itself—and I think it'll be interesting to actually see this at the meeting and visualize it and see how user-friendly and so on it is—but it comprises five modules, which integrate psychoeducation, behavior change, stress management, and they're delivered through a kind of interactive platform of educational games and videos. And then participants were self-reporting at baseline and then 60 days after transplant. So, around 125 patients were enrolled in this study, of around 174 who were initially approached. So, just over 70% uptake from caregivers, which is, I think, relatively high, and evenly distributed between the two randomized arms. And the majority of the participants were spouses. And at 60 days post-stem cell transplant, the intervention participants reported a better quality of life compared with those who received usual care. If you break this down a little bit more, these participants reported lower caregiving burden, lower incidence of depression, fewer PTSD symptoms, and overall better coping skills. So, the authors conclude that this particular app, a digital health intervention, led to pretty substantial improvements in quality of life for these caregivers. So, intriguing. As I said, it'll be particularly interesting to see how this thing looks during the meeting. But if these kind of results can be reproduced, I think this sort of application has potential uses way beyond the stem cell transplant setting. Dr. Erika Hamilton: Yeah, I find that just so fascinating and very needed. I think that the caregiving role is often underestimated in how important that is for the patient and the whole family, and really giving our caregivers more tools in their toolbox certainly is quite helpful. Dr. John Sweetenham: Absolutely. Well, the meeting is getting closer, and as I mentioned earlier, I think anticipation is mounting. And I wanted to say thanks so much to you for chatting with me today about some of the interesting advances in oncology that we're going to see at this year's meeting. There is a great deal more to come. Our listeners can access links to the studies we've discussed today in the transcript of this episode. I'm also looking forward, Dr. Hamilton, to having you back on the podcast after the Annual Meeting to dive into some of the late-breaking abstracts and some of the other key science that's captured the headlines this year. So, thanks once again for joining me today. Dr. Erika Hamilton: Thanks so much for having me. Pleasure. Dr. John Sweetenham: And thank you to our listeners for joining us today. Be sure to catch my “Top Takeaways from ASCO25.” These are short episodes that will drop each day of the meeting at 5:30 p.m. Eastern Time. So, subscribe to the ASCO Daily News Podcast wherever you prefer to listen, and join me for concise analyses of the meeting's key abstracts.   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.   More on today's speakers: Dr. John Sweetenham   Dr. Erika Hamilton @erikahamilton9   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. Erika Hamilton: Consulting or Advisory Role (Inst): Pfizer, Genentech/Roche, Lilly, Daiichi Sankyo, Mersana, AstraZeneca, Novartis, Ellipses Pharma, Olema Pharmaceuticals, Stemline Therapeutics, Tubulis, Verascity Science, Theratechnologies, Accutar Biotechnology, Entos, Fosun Pharma, Gilead Sciences, Jazz Pharmaceuticals, Medical Pharma Services, Hosun Pharma, Zentalis Pharmaceuticals, Jefferies, Tempus Labs, Arvinas, Circle Pharma, Janssen, Johnson and Johnson   Research Funding (Inst): AstraZeneca, Hutchison MediPharma, OncoMed, MedImmune, Stem CentRx, Genentech/Roche, Curis, Verastem, Zymeworks, Syndax, Lycera, Rgenix, Novartis, Millenium, TapImmune, Inc., Lilly, Pfizer, Lilly, Pfizer, Tesaro, Boehringer Ingelheim, H3 Biomedicine, Radius Health, Acerta Pharma, Macrogenics, Abbvie, Immunomedics, Fujifilm, eFFECTOR Therapeutics, Merus, Nucana, Regeneron, Leap Therapeutics, Taiho Pharmaceuticals, EMD Serono, Daiichi Sankyo, ArQule, Syros Pharmaceuticals, Clovis Oncology, CytomX Therapeutics, InventisBio, Deciphera, Sermonix Pharmaceuticals, Zenith Epigentics, Arvinas, Harpoon, Black Diamond, Orinove, Molecular Templates, Seattle Genetics, Compugen, GI Therapeutics, Karyopharm Therapeutics, Dana-Farber Cancer Hospital, Shattuck Labs, PharmaMar, Olema Pharmaceuticals, Immunogen, Plexxikon, Amgen, Akesobio Australia, ADC Therapeutics, AtlasMedx, Aravive, Ellipses Pharma, Incyte, MabSpace Biosciences, ORIC Pharmaceuticals, Pieris Pharmaceuticals, Pieris Pharmaceuticals, Pionyr, Repetoire Immune Medicines, Treadwell Therapeutics, Accutar Biotech, Artios, Bliss Biopharmaceutical, Cascadian Therapeutics, Dantari, Duality Biologics, Elucida Oncology, Infinity Pharmaceuticals, Relay Therapeutics, Tolmar, Torque, BeiGene, Context Therapeutics, K-Group Beta, Kind Pharmaceuticals, Loxo Oncology, Oncothyreon, Orum Therapeutics, Prelude Therapeutics, Profound Bio, Cullinan Oncology, Bristol-Myers Squib, Eisai, Fochon Pharmaceuticals, Gilead Sciences, Inspirna, Myriad Genetics, Silverback Therapeutics, Stemline Therapeutics

Host Dr. Nate Pennell and his guest, Dr. Chloe Atreya, discuss the ASCO Educational Book article, “Integrative Oncology: Incorporating Evidence-Based Approaches to Patients With GI Cancers,” highlighting the use of mind-body approaches, exercise, nutrition, acupuncture/acupressure, and natural products. Transcript Dr. Nate Pennell: Welcome to ASCO Education: By the Book, our new monthly podcast series that will feature engaging discussions between editors and authors from the ASCO Educational Book. We'll be bringing you compelling insights on key topics featured in Education Sessions at ASCO meetings and some deep dives on the approaches shaping modern oncology.  I'm Dr. Nate Pennell, director of the Cleveland Clinic Lung Cancer Medical Oncology Program as well as vice chair of clinical research for the Taussig Cancer Institute. Today, I'm delighted to welcome Dr. Chloe Atreya, a professor of Medicine in the GI Oncology Group at the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, and the UCSF Osher Center for Integrative Health, to discuss her article titled, “Integrative Oncology Incorporating Evidence-Based Approaches to Patients With GI Cancers”, which was recently published in the ASCO Educational Book. Our full disclosures are available in the transcript of this episode.  Dr. Atreya, it's great to have you on the podcast today. Thanks for joining me. Dr. Chloe Atreya: Thanks Dr. Pennell. It's a pleasure to be here. Dr. Nate Pennell: Dr. Atreya, you co-direct the UCSF Integrative Oncology Program with a goal to really help patients with cancer live as well as possible. And before we dive into the review article and guidelines, I'd love to just know a little bit about what inspired you to go into this field? Dr. Chloe Atreya: Yeah, thank you for asking. I've had a long-standing interest in different approaches to medicine from global traditions and I have a degree in pharmacology, and I continue to work on new drug therapies for patients with colorectal cancer. And one thing that I found is that developing new drugs is a long-term process and often we're not able to get the drugs to the patients in front of us. And so early on as a new faculty member at UCSF, I was trying to figure out what I could do for the patient in front of me if those new drug therapies may not be available in their lifetime. And one thing I recognized was that in some conversations the patient and their family members, even if the patient had metastatic disease, they were able to stay very present and to live well without being sidelined by what might happen in the future. And then in other encounters, people were so afraid of what might be happening in the future, or they may have regrets maybe about not getting that colonoscopy and that was eroding their ability to live well in the present.  So, I started asking the patients and family members who were able to stay present, “What's your secret? How do you do this?” And people would tell me, “It's my meditation practice,” or “It's my yoga practice.” And so, I became interested in this. And an entry point for me, and an entry point to the Osher Center at UCSF was that I took the Mindfulness-Based Stress Reduction Program to try to understand experientially the evidence for this and became very interested in it. I never thought I would be facilitating meditation for patients, but it became a growing interest. And as people are living longer with cancer and are being diagnosed at younger ages, often with young families, how one lives with cancer is becoming increasingly important.   Dr. Nate Pennell: I've always been very aware that it seemed like the patients that I treated who had the best quality of life during their life with cancer, however that ended up going, were those who were able to sort of compartmentalize it, where, when it was time to focus on discussing treatment or their scans, they were, you know, of course, had anxiety and other things that went along with that. But when they weren't in that, they were able to go back to their lives and kind of not think about cancer all the time. Whereas other people sort of adopt that as their identity almost is that they are living with cancer and that kind of consumes all of their time in between visits and really impacts how they're able to enjoy the rest of their lives. And so, I was really interested when I was reading your paper about how mindfulness seemed to be sort of like a formal way to help patients achieve that split. I'm really happy that we're able to talk about that. Dr. Chloe Atreya: Yeah, I think that's absolutely right. So, each of our patients is more than their cancer diagnosis. And the other thing I would say is that sometimes patients can use the cancer diagnosis to get to, “What is it that I really care about in life?” And that can actually heighten an experience of appreciation for the small things in life, appreciation for the people that they love, and that can have an impact beyond their lifetime. Dr. Nate Pennell: Just in general, I feel like integrative medicine has come a long way, especially over the last decade or so. So, there's now mature data supporting the incorporation of elements of integrative oncology into comprehensive cancer care. We've got collaborations with ASCO. They've published clinical practice guidelines around diet, around exercise, and around the use of cannabinoids. ASCO has worked with the Society for Integrative Oncology to address management of pain, anxiety, depression, fatigue – lots of different evidence bases now to try to help guide people, because this is certainly something our patients are incredibly interested in learning about. Can you get our listeners up to speed a little bit on the updated guidelines and resources supporting integrative oncology? Dr. Chloe Atreya: Sure. I can give a summary of some of the key findings. And these are rigorous guidelines that came together by consensus from expert panels. I had the honor of serving on the anxiety and depression panel. So, these panels will rate the quality of the evidence available to come up with a strength of recommendation. I think that people are at least superficially aware of the importance of diet and physical activity and that cannabis and cannabinoids have evidence of benefit for nausea and vomiting. They may not be aware of some of the evidence supporting these other modalities. So, for anxiety and depression, mindfulness-based interventions, which include meditation and meditative movement, have the strongest level of evidence. And the clinical practice guidelines indicate that they should be offered to any adult patient during or after treatment who is experiencing symptoms of anxiety or depression. Other modalities that can help with anxiety and depression include yoga and Tai Chi or Qigong. And with the fatigue guidelines, mindfulness-based interventions are also strongly recommended, along with exercise and cognitive behavioral therapy, Tai Chi and Qigong during treatment, yoga after treatment.  And some of these recommendations also will depend on where the evidence is. So, yoga is an example of an intervention that I think can be helpful during treatment, but most of our evidence is on patients who are post-treatment. So, most of our guidelines separate out during treatment and the post-treatment phase because the quality of evidence may be different for these different phases of treatment.  With the pain guidelines, the strongest recommendation is for acupuncture, specifically for people with breast cancer who may be experiencing joint pain related to aromatase inhibitors. However, acupuncture and other therapies, including massage, can be helpful with pain as well. So those are a few of the highlights. Dr. Nate Pennell: Yeah, I was surprised at the really good level of evidence for the mindfulness-based practices because I don't think that's the first thing that jumps to mind when I think about integrative oncology. I tend to think more about physical interventions like acupuncture or supplements or whatnot. So, I think this is really fantastic that we're highlighting this.  And a lot of these interventions like the Qigong, Tai Chi, yoga, is it the physical practice of those that benefits them or is it that it gives them something to focus on, to be mindful of? Is that the most important intervention? It doesn't really matter what you're doing as long as you have something that kind of takes you out of your experience and allows you to focus on the moment. Dr. Chloe Atreya: I do think it is a mind, body and spirit integration, so that all aspects are important. We also say that the best practice is the one that you actually practice. So, part of the reason that it's important to have these different modalities is that not everybody is going to take up meditation. And there may be people for whom stationary meditation, sitting and meditating, works well, and other people for whom meditative movement practices may be what they gravitate to. And so, I think that it's important to have a variety of options. And one thing that's distinct from some of our pharmacologic therapies is that the safety of these is, you know, quite good. So, it becomes less important to say, “Overall, is Tai Chi better or is yoga better?” for instance. It really depends on what it is that someone is going to take up. Dr. Nate Pennell: And of course, something that's been really nice evidence-based for a long time, even back when I was in my training in the 2000s with Jennifer Temel at Massachusetts General Hospital, was the impact of physical activity and exercise on patients with cancer. It seems like that is pretty much a universally good recommendation for patients. Dr. Chloe Atreya: Yes, that's absolutely right. Physical activity has been associated with improved survival after a cancer diagnosis. And that's both cancer specific survival and overall survival.  The other thing I'll say about physical activity, especially the mindful movement practices like Tai Chi and Qigong and yoga, is that they induce physiologic shifts in the body that can promote relaxation, so they can dampen that stress response in a physiologic way. And these movement practices are also the best way to reduce cancer-associated fatigue. Dr. Nate Pennell: One of the things that patients are always very curious about when they talk to me, and I never really feel like I'm as well qualified as I'd like to be to advise them around dietary changes in nutrition. And can you take me a little bit through some of the evidence base for what works and what doesn't work? Dr. Chloe Atreya: Sure. I do think that it needs to be tailored to the patient's needs. Overall, a diet that is plant-based and includes whole grains is really important. And I often tell patients to eat the rainbow because all of those different phytochemicals that cause the different colors in our fruits and vegetables are supporting different gut microbiota. So that is a basis for a healthy gut microbiome. That said, you know, if someone is experiencing symptoms related to cancer or cancer therapy, it is important to tailor dietary approaches. This is where some of the mindful eating practices can help. So, sometimes actually not just focusing on what we eat, but how we eat can help with symptoms that are associated with eating. So, some of our patients have loss of appetite, and shifting one's relationship to food can help with nutrition. Sometimes ‘slow it down' practices can help both with appetite and with digestion. Dr. Nate Pennell: One of the things that you said both in the paper and just now on our podcast, talking about how individualized and personalized this is. And I really liked the emphasis that you had on flexibility and self-compassion over rigid discipline and prescriptive recommendations here. And this is perhaps one of the real benefits of having an integrative oncology team that can work with patients as opposed to them just trying to find things online. Dr. Chloe Atreya: Yes, particularly during treatment, I think that's really important. And that was borne out by our early studies we called “Being Present.” So, after I was observing the benefits anecdotally among my patients of the ability to be present, we designed these pilot studies to teach meditation and meditative practices to patients. And in these pilot studies, the original ones were pretty prescriptive in a way that mindfulness-based stress reduction is fairly prescriptive in terms of like, “This is what we're asking you to do. Just stick with the program.” And there can be benefits if you can stick with the program. It's really hard though if someone is going through treatment and with GI cancers, it may be that they're getting chemotherapy every two weeks and they have one week where they're feeling really crummy and another week where they're trying to get things done. And we realized that sometimes people were getting overwhelmed and feeling like the mindfulness practice was another thing on their to-do list and that they were failing if they didn't do this thing that was important for them. And so, we've really kind of changed our emphasis. And part of our emphasis now is on incorporating mindfulness practices into daily life. Any activity that doesn't require a lot of executive function can be done mindfully, meaning with full attention. And so, especially for some of our very busy patients, that can be a way of, again, shifting how I'm doing things rather than adding a new thing to do. Dr. Nate Pennell: And then another part I know that patients are always very curious about that I'm really happy to see that we're starting to build an evidence base for is the use of supplements and natural products. So, can you take us a little bit through where we stand in terms of evidence behind, say, cannabis and some of the other available products out there? Dr. Chloe Atreya: Yeah, I would say that is an area that requires a lot more study. It's pretty complicated because unlike mindfulness practices where there are few interactions with other treatments, there is the potential for interactions, particularly with the supplements. And the quality of the supplements matters. And then there tends to be a lot of heterogeneity among the studies both in the patients and what other treatments they may be receiving, as well as the doses of the supplements that they're receiving.  One of my earliest mentors at Yale is someone named Dr. Tommy Chang, who has applied the same rigor that that we apply to testing of biomedical compounds to traditional Chinese medicine formulas. And so, ensuring that the formulation is stable and then formally testing these formulations along with chemotherapy. And we need more funding for that type of research in order to really elevate our knowledge of these natural products. We often will direct patients to the Memorial Sloan Kettering ‘About Herbs, Botanicals, and Other Products' database as one accessible source to learn more about the supplements. We also work with our pharmacists who can provide the data that exists, but we do need to take it with a grain of salt because of the heterogeneity in the data. And then it's really important if people are going to take supplements, for them to take supplements that are of high quality. And that's something in the article that we list all of the things that one should look for on the label of a supplement to ensure that it is what it's billed to be. Dr. Nate Pennell: So, most of what we've been talking about so far has really been applying to all patients with cancer, but you of course are a GI medical oncologist, and this is a publication in the Educational Book from the ASCO GI Symposium. GI cancers obviously have an incredibly high and rising incidence rate among people under 50, representing a quarter of all cancer incidence worldwide, a third of cancer related deaths worldwide. Is there something specific that GI oncologists and patients with GI cancers can take home from your paper or is this applicable to pretty much everyone? Dr. Chloe Atreya: Yeah, so the evidence that we review is specifically for GI cancers. So, it shows both its strengths and also some of the limitations. So many of the studies have focused on other cancers, especially breast cancer. In the integrative oncology field, there are definitely gaps in studying GI cancers. At the same time, I would say that GI cancers are very much linked to lifestyle in ways that are complicated, and we don't fully understand. However, the best ways that we can protect against development of GI cancers, acknowledging that no one is to blame for developing a GI cancer and no one is fully protected, but the best things that we can do for overall health and to prevent GI cancers are a diet that is plant-based, has whole grains. There's some data about fish that especially the deep-water fish, may be protective and then engaging in physical activity.  One thing I would like for people to take away is that these things that we know that are preventative against developing cancer are also important after development of a GI cancer. Most of the data comes from studies of patients with colorectal cancer and that again, both cancer specific and overall mortality is improved with better diet and with physical activity. So, this is even after a cancer diagnosis. And I also think that, and this is hard to really prove, but we're in a pretty inflammatory environment right now. So, the things that we can do to decrease stress, improve sleep, decrease inflammation in the body, and we do know that inflammation is a risk factor for developing GI cancers. So, I think that all of the integrative modalities are important both for prevention and after diagnosis. Dr. Nate Pennell: And one of the things you just mentioned is that most of the studies looking at integrative oncology and GI cancers have focused on colorectal cancer, which of course, is the most common GI cancer. But you also have pointed out that there are gaps in research and what's going on and what needs to be done in order to broaden some of this experience to other GI cancers. Dr. Chloe Atreya: Yeah, and I will say that there are gaps even for colorectal cancer. So right now, some of the authors on the article are collaborating on a textbook chapter for the Society for Integrative Oncology. And so, we're again examining the evidence specifically for colorectal cancer and are in agreement that the level of evidence specific to colorectal cancer is not as high as it is for all patients with adult cancers. And so even colorectal cancer we need to study more.  Just as there are different phases of cancer where treatments may need to be tailored, we also may need to tailor our treatments for different cancer types. And that includes what symptoms the patients are commonly experiencing and how intense the treatment is, and also the duration of treatment. Those are factors that can influence which modalities may be most important or most applicable to a given individual. Dr. Nate Pennell: So, a lot of this sounds fantastic. It sounds like things that a lot of patients would really appreciate working into their care. Your article focused a little bit on some of the logistics of providing this type of care, including group medical visits, multidisciplinary clinics staffed by multiple types of clinicians, including APPs and psychologists, and talked about the sustainability of this in terms of increasing the uptake of guideline-based integrative oncology. Talk a little bit more about both at your institution, I guess, and the overall health system and how this might be both sustainable and perhaps how we broaden this out to patients outside of places like UCSF. Dr. Chloe Atreya: Yes, that's a major focus of our research effort. A lot of comprehensive cancer centers and other places where patients are receiving care, people may have access to dietitians, which is really important and nutritionists. In the article we also provide resources for working with exercise therapists and those are people who may be working remotely and can help people, for instance, who may be in, in rural areas. And then our focus with the mind-body practices in particular has been on group medical visits. And this grew out of, again, my ‘being present' pilot studies where we were showing some benefit. But then when the grant ends, there isn't a way to continue to deliver this care. And so, we were asking ourselves, you know, is there a way to make this sustainable? And group medical visits have been used in other settings, and they've been working really well at our institution and other institutions are now taking them up as well. And this is a way that in this case it's me and many of my colleagues who are delivering these, where I can see eight or ten patients at once. In my case, it's a series of four two-hour sessions delivered by telehealth. So, we're able to focus on the integrative practices in a way that's experiential. So, in the clinic I may be able to mention, you know, after we go over the CT scans, after we go over the labs and the molecular profiling, you know, may be able to say, “Hey, you know, meditation may be helpful for your anxiety,” but in the group medical visits we can actually practice meditation, we can practice chair yoga. And that's where people have that experience in their bodies of these different modalities. And the feedback that we're receiving is that that sticks much more to experience it then you have resources to continue it. And then the group is helpful both in terms of delivery, so timely and efficient care for patients. It's also building community and reducing the social isolation that many of our patients undergoing treatment for cancer experience. Dr. Nate Pennell: I think that makes perfect sense, and I'm glad you brought up telehealth as an option. I don't know how many trained integrative oncologists there are out there, but I'm going to guess this is not a huge number out there. And much like other specialties that really can improve patients' quality of life, like palliative medicine, for example, not everyone has access to a trained expert in their cancer center, and things like telemedicine and telehealth can really potentially broaden that. How do you think telehealth could help broaden the exposure of cancer patients and even practitioners of oncology to integrative medicine? Dr. Chloe Atreya: Yes, I think that telehealth is crucial for all patients with cancer to be able to receive comprehensive cancer care, no matter where they're receiving their chemotherapy or other cancer-directed treatments. So, we will routinely be including patients who live outside of San Francisco. Most of our patients live outside of San Francisco. There's no way that they could participate if they had to drive into the city again to access this. And in the group setting, it's not even safe for people who are receiving chemotherapy to meet in a group most times. And with symptoms, often people aren't feeling so well and they're able to join us on Zoom in a way that they wouldn't be able to make the visit if it was in person. And so, this has really allowed us to expand our catchment area and to include patients, in our case, in all of California. You also mentioned training, and that's also important. So, as someone who's involved in the [UCSF] Osher Collaborative, there are faculty scholars who are at universities all over the US, so I've been able to start training some of those physicians to deliver group medical visits at their sites as well via telehealth. Dr. Nate Pennell: I'm glad we were able to make a plug for that. We need our political leadership to continue to support reimbursement for telehealth because it really does bring access to so many important elements of health care to patients who really struggle to travel to tertiary care centers. And their local cancer center can be quite a distance away.  So, sticking to the theme of training, clinician education and resources are really crucial to continue to support the uptake of integrative oncology in comprehensive cancer care. Where do you think things stand today in terms of clinician education and professional development in integrative oncology. Dr. Chloe Atreya: It's growing. Our medical students now are receiving training in integrative medicine, and making a plug for the Educational Book, I was really happy that ASCO let us have a table that's full of hyperlinks. So that's not typical for an article. Usually, you have to go to the reference list, but I really wanted to make it practical and accessible to people, both the resources that can be shared with patients that are curated and selected that we thought were of high-quality examples for patients. At the bottom of that table also are training resources for clinicians, and some of those include: The Center for Mind-Body Medicine, where people can receive training in how to teach these mind-body practices; The Integrated Center for Group Medical Visits, where people can learn how to develop their own group medical visits; of course, there's the Society for Integrative Oncology; and then I had just mentioned the Osher Collaborative Faculty Fellowship. Dr. Nate Pennell: Oh, that is fantastic. And just looking through, I mean, this article is really a fantastic resource both of the evidence base behind all of the elements that we've discussed today. Actually, the table that you mentioned with all of the direct hyperlinks to the resources is fantastic. Even recommendations for specific dietary changes after GI cancer diagnosis. So, I highly recommend everyone read the full paper after they have listened to the podcast today.  Before we wrap up, is there anything that we didn't get a chance to discuss that you wanted to make sure our listeners are aware of? Dr. Chloe Atreya: One thing that I did want to bring up is the disparities that exist in access to high quality symptom management care. So, patients who are racial and ethnic minorities, particularly our black and Latinx patients, the evidence shows that they aren't receiving the same degree of symptom management care as non-Hispanic White patients. And that is part of what may be leading to some of the disparities in cancer outcomes. So, if symptoms are poorly managed, it's harder for patients to stay with the treatment, and integrative oncology is one way to try to, especially with telehealth, this is a way to try to improve symptom management for all of our patients to help improve both their quality of life and their cancer outcomes. Dr. Nate Pennell: Well, Dr. Atreya, it's been great speaking with you today and thank you for joining me on the ASCO Education: By the Book Podcast and thank you for all of your work in advancing integrative oncology for GI cancers and beyond. Dr. Chloe Atreya: Thank you, Dr. Pennell. It's been a pleasure speaking with you. Dr. Nate Pennell: And thank you to all of our listeners who joined us today. You'll find a link to the article discussed today in the transcript of the episode. We hope you'll join us again for more insightful views on topics you'll be hearing at the Education Sessions from ASCO meetings throughout the year and our deep dives on approaches that are shaping modern oncology. Disclaimer: The purpose of this podcast is to educate, 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. Nathan Pennell   @n8pennell  @n8pennell.bsky.social  Dr. Chloe Atreya  Follow ASCO on social media:    @ASCO on X (formerly Twitter)    ASCO on Bluesky   ASCO on Facebook    ASCO on LinkedIn    Disclosures:   Dr. Nate Pennell:       Consulting or Advisory Role: AstraZeneca, Lilly, Cota Healthcare, Merck, Bristol-Myers Squibb, Genentech, Amgen, G1 Therapeutics, Pfizer, Boehringer Ingelheim, Viosera, Xencor, Mirati Therapeutics, Janssen Oncology, Sanofi/Regeneron      Research Funding (Institution): Genentech, AstraZeneca, Merck, Loxo, Altor BioScience, Spectrum Pharmaceuticals, Bristol-Myers Squibb, Jounce Therapeutics, Mirati Therapeutics, Heat Biologics, WindMIL, Sanofi   Dr. Chloe Atreya: Consulting or Advisory Role: Roche Genentech, Agenus Research Funding (Institution): Novartis, Merck, Bristol-Myers Squibb, Guardant Health, Gossamer Bio, Erasca, Inc.

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.  

On the inaugural episode of ASCO Education: By the Book, Dr. Nathan Pennell and Dr. Don Dizon share reflections on the evolution of the ASCO Educational Book, its global reach, and the role of its new companion podcast to further shine a spotlight on the issues shaping the future of modern oncology. TRANSCRIPT Dr. Nathan Pennell: Hello, I'm Dr. Nate Pennell, welcoming you to the first episode of our new podcast, ASCO Education: By the Book. The podcast will feature engaging discussions between editors and authors from the ASCO Educational Book. Each month, you'll hear nuanced views on key topics in oncology featured in Education Sessions at ASCO meetings, as well as some deep dives on the advances shaping modern oncology. Although I am honored to serve as the editor-in-chief (EIC) of the ASCO Educational Book, in my day job, I am the co-director of the Cleveland Clinic Lung Cancer Program and vice chair for clinical research for the Taussig Cancer Center here in Cleveland. I'm delighted to kick off our new podcast with a discussion featuring the Ed Book's previous editor-in-chief. Dr. Don Dizon is a professor of medicine and surgery at Brown University and works as a medical oncologist specializing in breast and pelvic malignancies at Lifespan Cancer Institute in Rhode Island. Dr. Dizon also serves as the vice chair for membership and accrual at the SWOG Cancer Research Network. Don, it's great to have you here for our first episode of ASCO Education: By the Book. Dr. Don Dizon: Really nice to be here and to see you again, my friend. Dr. Nathan Pennell: This was the first thing I thought of when we were kicking off a podcast that I thought we would set the stage for our hopefully many, many listeners to learn a little bit about what the Ed Book used to be like, how it has evolved over the last 14 years or so since we both started here and where it's going. You started as editor-in-chief in 2012, is that right? Dr. Don Dizon: Oh, boy. I believe that is correct, yes. I did two 5-year stints as EIC of the Educational Book, so that sounds about right. Although you're aging me very clearly on this podcast. Dr. Nathan Pennell: I had to go back in my emails to see if I could figure out when we started on this because we've been working on it for some time. Start out a little bit by telling me what do you remember about the Ed Book from back in the day when you were applying to be editor-in-chief and thinking about the Ed Book. What was it like at that time? Dr. Don Dizon: You know, it's so interesting to think about it.  Ten years ago, we were both in a very different place in our careers, and I remember when the Ed Book position came up, I had been writing a column for ASCO. I had done some editorial activities with other journals for sure, but what always struck me was it was very unclear how one was chosen to be a part of the education program at ASCO. And then it was very unclear how those faculty were then selected to write a paper for the Educational Book. And it was back in the day when the Educational Book was completely printed. So, there was this book that was cherished among American fellows in oncology. And it was one that, when I was newly attending, and certainly two or three years before the editor's position came up, it was one that I referenced all the time. So, it was a known commodity for many of us. And there was a certain sense of selectivity about who was invited to write in it. And it wasn't terribly transparent either. So, when the opportunity to apply for editor-in-chief of the Educational Book came up, I had already been doing so much work for ASCO. I had been on the planning committees and served in many roles across the organization, and editing was something I found I enjoyed in other work. So, I decided to put my name in the ring with the intention of sort of bringing the book forward, getting it indexed, for example, so that there was this credit that was more than just societal credit at ASCO. This ended up being something that was referenced and acknowledged as an important paper through PubMed indexing. And then also to provide it as a space where we could be more transparent about who was being invited and broadening the tent as to who could participate as an author in the Ed Book. Dr. Nathan Pennell: It's going to be surprising to many of our younger listeners to learn that the Educational Book used to be just this giant, almost like a brick. I mean, it was this huge tome of articles from the Education Sessions that you got when you got your meeting abstracts book at the annual meeting. And you can always see people on the plane on the way out of Chicago with their giant books. Dr. Don Dizon: Yes. Dr. Nathan Pennell: That added lots of additional weight to the plane, I'm sure, on the way out. Dr. Don Dizon: And it was not uncommon for us to be sitting at an airport, and people would be reading those books with highlighters. Dr. Nathan Pennell: I fondly remember being a fellow and coming up and the Ed Book was always really important to me, so I was excited. We'll also let the listeners in on that. I also applied to be the original editor-in-chief of the Ed Book back in 2012, although I was very junior and did not have any real editorial experience. I think I may have been section editor for The Oncologist at that point. And I had spoken to Dr. Ramaswamy Govindan at WashU who had been the previous editor-in-chief about applying and he was like, “Oh yeah. You should absolutely try that out.” And then when Dr. Dizon was chosen, I was like, “Oh, well. I guess I didn't get it.” And then out of the blue I got a call asking me to join as the associate editor, which I was really always very thankful for that opportunity. Dr. Don Dizon: Well, it was a highly fruitful collaboration, I think, between you and I when we first started. I do remember taking on the reins and sort of saying, “You know, this is our vision of what we want to do.” But then just working with the authors, which we did, about how to construct their papers and what we were looking for, all of that is something I look back really fondly on. Dr. Nathan Pennell: I think it was interesting too because neither one of us had really a lot of transparency into how things worked when we started. We kind of made it up a little bit as we went along. We wanted to get all of the faculty, or at least as many of them as possible contributing to these. And we would go to the ASCO Education Committee meeting and kind of talk about the Ed Book, and we were thinking about, you know, how could we get people to submit. So, at the time it wasn't PubMed indexed. Most people, I think, submitted individual manuscripts just from their talk, which could be anywhere from full length review articles to very brief manuscripts. Dr. Don Dizon: Sometimes it was their slides with like a couple of comments on it. Dr. Nathan Pennell: And some of them were almost like a summary of the talk. Yeah, exactly. And so sort of making that a little more uniform. There was originally an honorarium attached, which went away, but I think PubMed indexing was probably the biggest incentive for people to join. I remember that was one of the first things you really wanted to get. Dr. Don Dizon Yeah. And, you know, it was fortuitous. I'd like to take all the credit for it, but ASCO was very forward thinking with Dr. Ramaswamy and the conversations about going to PubMed with this had preceded my coming in. We knew what we needed to do to get this acknowledged, which was really strengthening the peer review so that these papers could meet the bar to get on PubMed. But you know, within the first, what, two or three years, Nate, of us doing this, we were able to get this accepted. And now it is. If you look at what PubMed did for us, it not only increased the potential of who was going to access it, but for, I think the oncology community, it allowed people access to papers by key opinion leaders that was not blocked by a paywall. And I thought that was just super important at the time. Social media was something, but it wasn't what it is now. But anybody could access these manuscripts and it's still the case today. Dr. Nathan Pennell: I think it's hard to overstate how important that was. People don't realize this, but the Ed Book is really widely accessed, especially outside the US as well. And a lot of people who can't attend the meeting to get the print, well, the once print, book could actually get access to essentially the education session from the annual meeting without having to fly all the way to the US to attend. Now, you know, we have much better virtual meeting offerings now and whatnot. But at the time it was pretty revolutionary to be able to do that. Dr. Don Dizon: Yeah, and you know, it's so interesting when I think back to, you know, this sort of evolution to a fully online publication of the Ed Book. It was really some requests from international participants of the annual meeting who really wanted to continue to see this in print. At that time, it was important to recognize that access to information was not uniform across the world. And people really wanted that print edition, maybe not for themselves, but so that access in more rural areas or where access in the broadband networks were not established that they still could access the book. I think things have changed now. We were able, I think, in your tenure, to see it fully go online. But even I just remember that being a concern as we went forward. Dr. Nathan Pennell: Yeah, we continued with the print book that was available if people asked for it, but apparently few enough people asked for it that it moved fully online. One of the major advantages of being fully online now is of course, it does allow us to publish kind of in real time as the manuscripts come out in the months leading up to the meeting, which has been, I think, a huge boon because it can build momentum for the Education Sessions coming in. People, you know, really look forward to it. Dr. Don Dizon: Yeah, that was actually a concern, you know, when we were phasing out Ed Book and going to this continuous publication model where authors actually had the ability to sort of revise their manuscript and that would be automatically uploaded. You had a static manuscript that was fully printed, and it was no longer an accurate one. And we did have the ability to fix it. And it just goes to show exactly what you're saying. This idea that these are living papers was really an important thing that ASCO embraced quite early, I think. Dr. Nathan Pennell: And with the onset of PubMed indexing, the participation from faculty skyrocketed and almost within a couple of years was up to the vast majority of sessions and faculty participating. Now I think people really understand that this is part of the whole process. But at the time I remember writing out on my slides in all caps, “THIS IS AN EXPECTATION.” And that's about the best word I could give because I asked if we could make people do it, and they were like, no, you can't make people do it. Dr. Don Dizon: So right.  Actually, I don't think people are aware of the work on the back end every year when I was on as EIC, Nate and myself, and then subsequently Dr. Hope Rugo would have these informational sessions with the education faculty and we would tout the Ed Book, tout the expectation, tout it was PubMed indexed and tout multidisciplinary participation. So, we were not seeing four manuscripts reflecting one session. You know, this encouragement to really embrace multidisciplinary care was something that very early on we introduced and really encouraged people not to submit perspective manuscripts, but to really get them in and then harmonize the paper so that it felt like it was, you know, one voice. Dr. Nathan Pennell: I consider that after PubMed indexing, the next major change to the Ed Book, that really made it a better product and that was moving from, you know, just these short individual single author manuscripts to single session combined manuscript that had multiple perspectives and topics, really much more comprehensive review articles. And I don't even remember what the impetus was for that, but it was really a success. Dr. Don Dizon: Yeah, I mean, I think in the beginning it was more of a challenge, I think, because people were really not given guidance on what these papers were supposed to look like. So, we were seeing individual manuscripts come forward. Looking back, it really foreshadowed the importance of multidisciplinary management. But at the time, it was really more about ensuring that people were leaving the session with a singular message of what to do when you're in clinic again. And the goal was to have the manuscripts reflect that sort of consensus view of a topic that was coming in. There were certain things that people still argued would not fit in a multidisciplinary manuscript. You know, if you have someone who's writing and whose entire talk was on the pathology of thyroid cancer. Another topic was on survivorship after thyroid cancer. It was hard to sort of get those two to interact and cover what was being covered. So, we were still getting that. But you're right, at the end of my tenure and into yours, there were far fewer of those individual manuscripts. Dr. Nathan Pennell: And I think it's even made it easier to write because now, you know, you just have to write a section of a manuscript and not put together an entire review. So, it has helped with getting people on board. Dr. Don Dizon: Well, the other thing I thought was really interesting about the process is when you're invited to do an Education Session at ASCO, you're either invited as a faculty speaker or as the chair of the session. And the responsibility of the chair is to ensure that it flows well and that the talks are succinct based on what the agenda or the objectives were as defined by the education committee for that specific group. But that was it. So really being named “Chair” was sort of an honor, an honorific. It really didn't come with responsibility. So, we use the Ed Book as a way to say, “As chair of the session, it is your responsibility to ensure A, a manuscript comes to me, but B, that the content of that paper harmonizes and is accurate.” And it was very rare, but Nate, I think we got dragged into a couple of times where the accuracy of the manuscript was really called into question by the chair. And those were always very, very tricky discussions because everyone that gets invited to ASCO is a recognized leader in their field. Some of us, especially, I would probably say, dating back 10 years from today, the data behind Standards of Care were not necessarily evidence-based. So, there were a lot of opinion-based therapies. You know, maybe not so much in the medical side, but certainly some of it. But when you went to, you know, surgical treatments and maybe even radiotherapy treatments, it was really based on, “My experience at my center is this and this is why I do what I do.” But those kinds of things ended up being some of the more challenging things to handle as an editor. Dr. Nathan Pennell: And those are the– I'll use “fun” in a broad sense. You know, every once in a while, you get an article where it really does take a lot of hands-on work from the editor to work with the author to try to revise it and make it a suitable academic manuscript. But you know what? I can't think, at least in recent years, of any manuscripts that we turned down. They just sometimes needed a little TLC. Dr. Don Dizon: Yeah. And I think the other important thing it reminds me of is how great it was that I wasn't doing this by myself. Because it was so great to be able to reach out to you and say, “Can you give me your take on this paper?” Or, “Can you help me just join a conference call with the authors to make sure that we're on the same page?” And then on the rare example where we were going to reject a paper, it was really important that we, as the editorial team, and I include our ASCO shepherder, through the whole process. We had to all agree that this was not salvageable. Fortunately, it happened very rarely. But I've got to say, not doing this job alone was one of the more important facets of being the EIC of ASCO's Educational Book. Dr. Nathan Pennell: Well, it's nice to hear you say that. I definitely felt that this was a partnership, you know, it was a labor of love. So, I want to go to what I consider sort of the third major pillar of the changes to the Ed Book during your tenure, and that was the introduction of a whole new kind of manuscript. So up to, I don't know, maybe seven or eight years ago, all the articles were authored just by people who were presenting at the Annual Meeting. And then you had an idea to introduce invited manuscripts. So take me through that. Dr. Don Dizon: Yeah, well, you know, again, it went to this sort of, what can people who are being asked to sort of lead ASCO for that year, what can they demonstrate as sort of a more tangible contribution to the Society and to oncology in general? And I think that was the impetus to use the Ed Book for everyone who was in a leadership position to make their mark. That said, I was here, and I was either president of the society or I was Education Program Chair or Scientific Program Chair, and they got to select an article type that was not being covered in the annual meeting and suggest the authors and work with those authors to construct a manuscript. Never did any one of those folks suggest themselves, which I thought was fascinating. They didn't say, “I want to be the one to write this piece,” because this was never meant to be a presidential speech or a commemorative speech or opportunity for them as leaders. But we wanted to ensure that whatever passion they had within oncology was represented in the book. And again, it was this sort of sense of, I want everyone to look at the Ed Book and see themselves in it and see what they contributed. And that was really important for those who were really shepherding each Annual Meeting each year for ASCO that they had the opportunity to do that. And I was really pleased that leadership really took to that idea and were very excited about bringing ideas and also author groups into the Educational Book who would not have had the opportunity otherwise. I thought that was just really nice. It was about inclusiveness and just making sure that people had the opportunity to say, “If you want to participate, we want you to participate.” Dr. Nathan Pennell: Yeah, I agree. I think the ASCO leadership jumped on this and continues to still really appreciate the opportunity to be able to kind of invite someone on a topic that's meaningful to them. I think we've tried to work in things that incorporate the presidential theme each year in our invited manuscript, so it really allows them to put kind of a stamp on the flavor of each edition. And the numbers reflect that these tend to be among our more highly read articles as well. Dr. Don Dizon: You know, looking back on what we did together, that was something I'm really, really quite proud of, that we were able to sort of help the Educational Book evolve that way. Dr. Nathan Pennell: I agree. You brought up briefly a few minutes ago about social media and its role over time. I think when we started in 2012, I had just joined Twitter now X in 2011, and I think we were both sort of early adopters in the social media. Do you feel like social media has had a role in the growth of the Ed Book or is this something that you think we can develop further? Dr. Don Dizon: When we were doing Ed Book together, professional social media was actually a quite identified space. You know, we were all on the same platform. We analyzed what the outcomes were on that platform and our communities gathered on that platform. So, it was a really good place to highlight what we were publishing, especially as we went to continuous publishing.  I don't remember if it was you or me, but we even started asking our authors for a tweet and those tweets needed work. It was you. It was you or I would actually lay in these tweets to say, “Yeah, we need to just, you know, work on this.” But I think it's harder today. There's no one preferred platform. Alternate platforms are still evolving. So, I think there are opportunities there. The question is: Is that opportunity meaningful enough for the Ed Book to demonstrate its return on an investment, for example? What I always thought about social media, and it's still true today, is that it will get eyes on whatever you're looking at far beyond who you intended to see it. So, you know, your tweets regarding a phase 3 clinical trial in lung cancer, which were so informative, were reaching me, who was not a lung oncologist who doesn't even see lung cancer and getting me more interested in finding that article and more and more pointing to the Educational Book content that speaks to that piece, you know. And I think coupling an impression of the data, associating that with something that is freely accessed is, I think, a golden opportunity not only for our colleagues, but also for anyone who's interested in a topic. Whether you are diagnosed with that cancer or you are taking care of someone with that cancer, or you heard about that cancer, there are people who would like to see information that is relevant and embedded and delivered by people who know what they're talking about. And I think our voices on social media are important because of it. And I think that's where the contribution is. So, if we had to see what the metric was for any social media efforts, it has to be more of the click rates, not just by ASCO members, but the click rates across societies and across countries. Dr. Nathan Pennell: Yeah, social media is, I mean, obviously evolving quite a bit in the last couple of years. But I do know that in terms the alt metrics for the track access through social media and online, the ones that are shared online by the authors, by the Ed Book team, do seem to get more attention. I think a lot of people don't like to just sit with a print journal anymore or an email table of contents for specific journals. People find these articles that are meaningful to them through their network and oftentimes that is online on social media. Dr. Don Dizon: Yes, 100%. And you know what I think we should encourage people to do is look at the source. And if the Ed Book becomes a source of information, I think that will be a plus to the conversations in our world. We're still dealing with a place where, depending on who sponsored the trial, whether it was an industry-sponsored trial, whether it was NCI sponsored or sponsored by the National Institutes of Health, for example, access to the primary data sets may or may not be available across the world, but the Ed Book is. And if the Ed Book can summarize that data and use terms and words that are accessible no matter what your grade level of education is. If we can explain the graphs and the figures in a way that people can actually easily more understand it. If there's a way that we structure our conversations in the Ed Book so that the plethora of inclusion/exclusion criteria are summarized and simplified, then I think we can achieve a place where good information becomes more accessible, and we can point to a summary of the source data in places where the source is not available. Dr. Nathan Pennell: One of the other things that I continue to be surprised at how popular these podcasts are. And that gives you an opportunity pretty much the opposite. Instead of sort of a nugget that directs you to the source material, you've got a more in-depth discussion of the manuscript. And so, I'm delighted that we have our own podcast. For many years, the Ed Book would sort of do a sort of a “Weird Al takeover” of the ASCO Daily News Podcast for a couple of episodes around the Annual Meeting, and I think those were always really popular enough that we were able to argue that we deserved our own podcast. And I'm really looking forward to having these in-depth discussions with authors. Dr. Don Dizon: It's an amazing evolution of where the Ed Book has gone, right? We took it from print only, societally only, to something that is now accessed worldwide via PubMed. We took it from book to fully online print. And now I think making the content live is a natural next step. So, I applaud you for doing the podcast and giving people an opportunity actually to discuss what their article discusses. And if there's a controversial point, giving them the freedom and the opportunity to sort of give more nuanced views on what may not be something that there's 100% consensus over. Dr. Nathan Pennell: Yes. Well, I hope other people enjoy these as well. Just want to highlight a few of the things that have happened just in the couple years since you stepped down as editor-in-chief. One of them, and I don't know if you noticed, but last year we started adding manuscripts from the ASCO thematic meetings, so ASCO GI and ASCO GU, something we had certainly talked about in the past, but had lacked bandwidth to really do. And they seem to be pretty widely accessed. Dr. Don Dizon: That's fantastic. Yes, I do remember talking about the coverage of the thematic meetings and you're right, this takes a long time to sort of concentrate on the Annual Meeting. It may seem like everything happens in the span of like eight weeks. Dr. Nathan Pennell: It does feel like that sometimes. Dr. Don Dizon: Right? But this is actually something that starts a year before, once the education program is set. We're in the room when they set it. But then it's really chasing down manuscripts and then making sure that they're peer reviewed because the peer review is still really important, and then making sure that any revisions are made before it's finalized and goes to press. That is a many months process. So, when we're trying to introduce, “Oh, we should also do ASCO GU or-,” the question was, how do you want to do that given this very, very involved process going forward? So, I'm glad you were able to figure it out. Dr. Nathan Pennell: Well, it's challenging. I don't think people realize quite the compressed timeline for these. You know, the Education Session and authors and invited faculty are picked in the fall, and then basically you have to start turning in your manuscripts in February, March of the following year. And so, it's a really tight turnaround for this. When we talk about the ASCO thematic meetings, it's an even tighter window. Dr. Don Dizon: Right, exactly. Dr. Nathan Pennell: And so, it's challenging to get that moving, but I was really, really proud that we were able to pull that off. Dr. Don Dizon: Well, congratulations again. And I think that is a necessary step, because so much of what's going on in the various disease management sites is only covered cursorily through the Annual Meeting itself. I mean, there's just so much science breaking at any one time that I think if we want to comprehensively catalog the Year in Review in oncology, it kind of behooves us to do that. Dr. Nathan Pennell: Some other things that are coming up because we now have manuscripts that are going to be coming in year-round, and just to kind of make it easier on the editorial staff, we're going to be forming an editorial board. And in addition to our pool of reviewers who get ASCO points, please feel free to go online to the ASCO volunteer portal and sign up if you are interested in participating. So, moving forward, I'm really excited to see where things are going to go. Dr. Don Dizon: Well, that's great. That's great. And I do remember talking about whether or not we needed to have an editorial board. At least when I was there, having this carried by three people was always better than having it carried by one person. And I think as you expand the potential for submissions, it will be very helpful to have that input for sure. And then it gives another opportunity for more members to get involved in ASCO as well. Dr. Nathan Pennell: Absolutely. People want involvement, and so happy to provide that. Dr. Don Dizon: Yes. Dr. Nathan Pennell: Is there anything we didn't cover that you would like to mention before we wrap up? Dr. Don Dizon: Well, I will say this, that ASCO and through its publications not only has had this real emphasis on multidisciplinary management of cancers, especially where it was relevant, but it also always had a stand to ensure representation was front and center and who wrote for us. And I think every president, every chair that I've worked with naturally embraced that idea of representation. And I think it has been a distinct honor to say that during my tenure as EIC, we have always had a plethora of voices, of authors from different countries, of genders, that have participated in the construction of those books. And it stands as a testament that we are a global community and we will always be one. Dr. Nathan Pennell: Well, thank you for that. And I'm happy to continue that as we move forward. Well, Don, thank you. It's been great speaking with you. You played such a pivotal role in the Ed Book's evolution and I'm so glad you were able to join me for our inaugural episode. Dr. Don Dizon: Well, I'm just tickled that you asked me to be your first guest. Thank you so much, Nate. Dr. Nathan Pennell: And I also want to thank our listeners for joining us today. We hope you'll join us again for more insightful views on topics you'll be hearing at the Education Sessions from ASCO meetings throughout the year, as well as our periodic deep dives on advances that are shaping modern oncology. Have a great day. 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. Nathan Pennell  @n8pennell @n8pennell.bsky.social   Dr. Don Dizon @drdondizon.bsky.social  Follow ASCO on social media:   @ASCO on X (formerly Twitter)   ASCO on Bluesky  ASCO on Facebook   ASCO on LinkedIn   Disclosures:  Dr. Nathan Pennell:      Consulting or Advisory Role: AstraZeneca, Lilly, Cota Healthcare, Merck, Bristol-Myers Squibb, Genentech, Amgen, G1 Therapeutics, Pfizer, Boehringer Ingelheim, Viosera, Xencor, Mirati Therapeutics, Janssen Oncology, Sanofi/Regeneron     Research Funding (Inst): Genentech, AstraZeneca, Merck, Loxo, Altor BioScience, Spectrum Pharmaceuticals, Bristol-Myers Squibb, Jounce Therapeutics, Mirati Therapeutics, Heat Biologics, WindMIL, Sanofi  Dr. Don Dizon: Stock and Other Ownership Interests: Midi, Doximity Honoraria: UpToDate, American Cancer Society Consulting or Advisory Role: AstraZeneca, Clovis Oncology, Kronos Bio, Immunogen Research Funding (Institution): Bristol-Myers Squibb          

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  

Dr. Ebony Hoskins and Dr. Andreas Obermair discuss the surgical management of gynecologic cancers, including the role of minimally invasive surgery, approaches in fertility preservation, and the nuances of surgical debulking. TRANSCRIPT Dr. Ebony Hoskins: Hello and welcome to the ASCO Daily News Podcast, I'm Dr. Ebony Hoskins. I'm a gynecologic oncologist at MedStar Washington Hospital Center in Washington, DC, and your guest host of the ASCO Daily News Podcast. Today we'll be discussing the surgical management of gynecologic cancer, including the role of minimally invasive surgery (MIS), approaches in fertility preservation, and the nuances of surgical debulking, timing, and its impact on outcomes. I am delighted to welcome Dr. Andreas Obermair for today's discussion. Dr. Obermair is an internationally renowned gynecologic oncologist, a professor of gynecologic oncology at the University of Queensland, and the head of the Queensland Center for Gynecologic Cancer Research. Our full disclosures are available in the transcript of this episode. Dr. Obermair, it's great speaking with you today. Dr. Andreas Obermair: Thank you so much for inviting me to this podcast. Dr. Ebony Hoskins: I am very excited.  I looked at your paper and I thought, gosh, is everything surgical? This is everything that I deal with daily in terms of cancer in counseling patients. What prompted this review regarding GYN cancer management? Dr. Andreas Obermair: Yes, our article was published in the ASCO Educational Book; it is volume 44 in 2024. And this article covers some key aspects of targeted precision surgical management principles in endometrial cancer, cervical cancer, and ovarian cancer. While surgery is considered the cornerstone of gynecologic cancer treatment, sometimes research doesn't necessarily reflect that. And so I think ASCO asked us to; so it was not just me, there was a team of colleagues from different parts of the United States and Australia to reflect on surgical aspects of gynecologic cancer care and I feel super passionate about that because I do believe that surgery has a lot to offer. Surgical interventions need to be defined and overall, I see the research that I'm doing as part of my daily job to go towards precision surgery. And I think that is, well, that is something that I'm increasingly passionate for. Dr. Ebony Hoskins: Well, I think we should get into it. One thing that comes to mind is the innovation of minimally invasive surgery in endometrial cancer. I always reflect on when I started my fellowship, I guess it's been about 15 years ago, all of our endometrial cancer patients had a midline vertical incision, increased risk of abscess, infections and a long hospital stay. Do you mind commenting on how you see management of endometrial cancer today? Dr. Andreas Obermair: Thank you very much for giving the historical perspective because the generation of gynecologic oncologists today, they may not even know what we dealt with, what problems we had to solve. So like you, when I was a fellow in gynecologic oncology, we did midline or lower crosswise incisions, the length of stay was, five days, seven days, but we had patients in hospital because of complications for 28 days. We took them back to the operating theaters because those are patients with a BMI of 40 plus, 45, 50 and so forth. So we really needed to solve problems. And then I was exposed to a mentor who taught minimal invasive surgery. And in Australia he was one of the first ones who embarked on that. And I can remember, I was mesmerized by this operation, like not only how logical this procedure was, but also we did rounds afterwards. And I saw these women after surgery and I saw them sitting upright, lipstick on, having had a full meal at the end of the day. And I thought, wow, this is the most rewarding experience that I have to round these patients after surgery. And so I was thinking, how could I help to establish this operation as standard? Like a standard that other people would accept this is better. And so I thought we needed to do a trial on this. And then it took a long time. It took a long time to get the support for the [LACE - Laparoscopic Approach to Cancer of the Endometrium] trial. And in this context, I just also wanted to remind us all that there were concerns about minimal invasive surgery in endometrial cancer at the time. So for example, one of the concerns was when I submitted my grant funding applications, people said, “Well, even if we fund you, wouldn't be able to do this trial because there are actually no surgeons who actually do minimally invasive surgery.” And at the time, for example, in Australia, there were maybe five people, a handful of people who were able to do this operation, right? This was about 20 years ago. The other concern people had was they were saying, could minimally invasive surgery for endometrial cancer, could that cause port side metastasis because there were case reports. So there were a lot of things that we didn't know anyway. We did this trial and I'm super happy we did this trial. We started in 2005, and it took five years to enroll. At the same time, GOG LAP2 was ramping up and the LACE trial and GOG LAP2 then got published and provided the foundations for minimally invasive surgery in endometrial cancer. I'm super happy that we have randomized data about that because now when we go back and now when people have concerns about this, should we do minimally invasive surgery in P53 mutant tumors, I'm saying, well, we actually have data on that. We could go back, we could actually do more research on that if we wanted to, but our treatment recommendations are standing on solid feet. Dr. Ebony Hoskins: Well, my patients are thankful. I see patients all the time and they have high risk and morbidly obese, lots of medical issues and actually I send them home most the same day. And I think, you know, I'm very appreciative of that research, because we obviously practice evidence-based and it's certainly a game changer. Let's go along the lines of MIS and cervical cancer. And this is going back to the LACC [Laparoscopic Approach to Cervical Cancer] trial.  I remember, again, one of these early adopters of use of robotic surgery and laparoscopic surgery for radical hysterectomy and thought it was so cool. You know, we can see all the anatomy well and then have the data to show that we actually had a decreased survival. And I even see that most recent updated data just showing it still continued. Can you talk a little bit about why you think there is a difference? I know there's ongoing trials, but still interested in kind of why do you think there's a survival difference? Dr. Andreas Obermair:  So Ebony, I hope you don't mind me going back a step. So the LACC study was developed from the LACE trial. So we thought we wanted to reproduce the LACE data/LAP2 data. We wanted to reproduce that in cervix cancer. And people were saying, why do you do that? Like, why would that be different in any way? We recognize that minimally invasive radical hysterectomy is not a standard. We're not going to enroll patients in a randomized trial where we open and do a laparotomy on half the patients. So I think the lesson that really needs to be learned here is that any surgical intervention that we do, we should put on good evidence footing because otherwise we're really running the risk of jeopardizing patients' outcomes. So, that was number one and LACC started two years after LACE started. So LACC started in 2007, and I just wanted to acknowledge the LACC principal investigator, Dr. Pedro Ramirez, who at the time worked at MD Anderson. And we incidentally realized that we had a common interest. The findings came totally unexpected and came as an utter shock to both of us. We did not expect this. We expected to see very similar disease-free and overall survival data as we saw in the endometrial cancer cohort. Now LACC was not designed to check why there was a difference in disease-free survival. So this is very important to understand. We did not expect it. Like, so there was no point checking why that is the case. My personal idea, and I think it is fair enough if we share personal ideas, and this is not even a hypothesis I want to say, this is just a personal idea is that in endometrial cancer, we're dealing with a tumor where most of the time the cancer is surrounded by a myometrial shell. And most of the time the cancer would not get into outside contact with the peritoneal cavity. Whereas in cervix cancer, this is very different because in cervix cancer, we need to manipulate the cervix and the tumor is right at the outside there. So I personally don't use a uterine manipulator. I believe in the United States, uterine manipulators are used all the time. My experience is not in this area, so I can't comment on that. But I would think that the manipulation of the cervix and the contact of the cervix to the free peritoneal cavity could be one of the reasons. But again, this is simply a personal opinion. Dr. Ebony Hoskins: Well, I appreciate it. Dr. Andreas Obermair: Ebony at the end of the day, right, medicine is empirical science, and empirical science means that we just make observations, we make observations, we measure them, and we pass them on. And we made an observation. And, and while we're saying that, and yes, you're absolutely right, the final [LACC] reports were published in JCO recently. And I'm very grateful to the JCO editorial team that they accepted the paper, and they communicated the results because this is obviously very important. At the same time, I would like to say that there are now three or four RCTs that challenge the LACC data. These RCTs are ongoing, and a lot of people will be looking forward to having these results available. Dr. Ebony Hoskins: Very good. In early-stage cervical cancer, the SHAPE trial looked at simple versus radical hysterectomy in low-risk cervical cancer patients. And as well all know, simple hysterectomy was not inferior to radical hysterectomy with respect to the pelvic recurrence rate and any complications related to surgery such as urinary incontinence and retention. My question for you is have you changed your practice in early-stage cervical cancer, say a patient with stage 1B1 adenocarcinoma with a positive margin on conization, would you still offer this patient a radical hysterectomy or would you consider a simple hysterectomy? Dr. Andreas Obermair:  I think this is a very important topic, right? Because I think the challenge of SHAPE is to understand the inclusion criteria. That's the main challenge. And most people simplify it to 2 cm, which is one of the inclusion criteria but there are two others and that includes the depth of invasion. Dr. Marie Plante has been very clear. Marie Plante is the first author of the SHAPE trial that's been published in the New England Journal of Medicine only recently and Marie has been very clear upfront that we need to consider all three inclusion criteria and only then the inclusion criteria of SHAPE apply. So at the end of the day, I think what the SHAPE trial is telling us that small tumors that would strictly fulfill the criteria of a 1B or 1B1 cancer of the cervix can be considered for a standard type 1 or PIVA type 1 or whatever classification we're trying to use will be eligible. And that makes a lot of sense. I personally not only look at the size, I also look at the location of the tumor. I would be very keen that I avoid going through tumor tissue because for example, if you have a tumor that is, you know, located very much in one corner of the cervix and then you do a standard hysterectomy and then you have a positive tumor margin that would be obviously, most people would agree it would be an unwanted outcome. So I'd be very keen checking the location, the size of the tumor, the depths of invasion and maybe then if the tumor for example is on one side of the cervix you can do a standard approach on the contralateral side but maybe do a little bit more of a margin, a parametrial margin on the other side. Or if a tumor is maybe on the posterior cervical lip, then you don't need to worry so much about the anterior cervical margin, maybe take the rectum down and maybe try to get a little bit of a vaginal margin and the margin on the uterus saccals. Just really to make sure that you do have margins because typically if we get it right, survival outcomes of clinical stage 1 early cervix cancer 1B1 1B 2 are actually really good. It is a very important thing that we get the treatment right. In my practice, I use a software to record my treatment outcomes and my margins. And I would encourage all colleagues to be cognizant and to be responsible and accountable to introduce accountable clinical practice, to check on the margins and check on the number on the percentage of patients who require postoperative radiation treatment or chemo radiation. Dr. Ebony Hoskins: Very good. I have so many questions for you. I don't know the statistics in Australia, but here, there's increased rising of endometrial cancer and certainly we're seeing it in younger women. And fertility always comes up in terms of kind of what to do. And I look at the guidelines and, see if I can help some of the women if they have early-stage endometrial cancer. Your thoughts on what your practice is on use of someone who may meet criteria, if you will. The criteria I use is grade 1 endometrioid adenocarcinoma. No myometria invasion. I try to get MRI'd and make sure that there's no disease outside the endometrium. And then if they make criteria, I typically would do an IUD. Can you tell me what your practice is and where you've had success? Dr. Andreas Obermair: So, we initiated the feMMe clinical trial that was published in 2021 and it was presented in a Plenary at one of the SGO meetings. I think it was in 2021, and we've shown complete pathological response rates after levonorgestrel intrauterine device treatment. And so in brief, we enrolled patients with endometrial hyperplasia with atypia, but also patients with grade 1 endometrial adenocarcinoma. Patients with endometrial hyperplasia with atypia had, in our series, had an 85 % chance of developing a complete pathological response. And that was defined as the complete absence of any atypia or cancer. So endometrial hyperplasia with atypia responded in about 85%. In endometrial cancer, it was about half, it was about 45, 50%. In my clinical practice, like as you, I see patients, you know, five days a week. So I'm looking after many patients who are now five years down from conservative treatment of endometrial cancer. There are a lot of young women who want to get pregnant, and we had babies, and we celebrate the babies obviously because as gynecologist obstetricians it couldn't get better than that, right, if our cancer patients have babies afterwards. But we're also treating women who are really unfit for surgery and who are frail and where a laparoscopic hysterectomy would be unsafe. So this phase is concluded, and I think that was very successful. At least we're looking to validate our data. So we're having collaborations, we're having collaborations in the United States and outside the United States to validate these data. And the next phase is obviously to identify predictive factors, to identify predictors of response. Because as you can imagine, there is no point treating patients with a levonorgestrel intrauterine joint device where we know in advance that she's not going to respond. So this is a very, very fascinating story and we got our first set of data already, but now we just really need to validate this data. And then once the validation is done, my unit is keen to do a prospective validation trial. And that also needs to involve international collaborators. Dr. Ebony Hoskins: Very good. Moving on to ovarian cancer, we see patients with ovarian cancer with, say, at least stage 3C or higher who started neoadjuvant chemotherapy. Now, some of these patients are hearing different things from their medical oncologist versus their gynecologic oncologist regarding the number of cycles of neoadjuvant chemotherapy after getting diagnosed with ovarian cancer. I know that this can be confusing for our patients coming from a medical oncologist versus a gynecologic oncologist. What do you say to a patient who is asking about the ideal number of chemotherapy cycles prior to surgery? Dr. Andreas Obermair: So this is obviously a very, very important topic to talk about. We won't be able to provide a simple off the shelf answer for that, but I think data are emerging.  The ASCO guidelines should also be worthwhile considering because there are actually new ASCO Guidelines [on neoadjuvant chemotherapy for newly diagnosed, advanced ovarian cancer] that just came out a few weeks ago and they would suggest that we should be aiming for R0 in surgery. If we can maybe take that as the pivot point and then go back and say, okay, so what do need to do to get the patient to zero?  I'm not an ovarian cancer researcher; I'm obviously a practicing gynecologic oncologist. I think about things a lot and things like that. In my practice, I would want a patient to develop a response after neoadjuvant chemotherapy. So, if a patient doesn't have a response after two or three cycles, then I don't see the point for me to offer her an operation. In my circle with the medical oncologists that I work with, I have a very, very good understanding. So, they send the patient to me, I take them to the theater. I take a good chunk of tissue from the peritoneum. We have a histopathologic diagnosis, we have a genomic diagnosis, they go home the same day. So obviously there is no hospital stay involved with that. They can start the chemotherapy after a few days. There is no hold up because the chances of surgical complication in a setting like this is very, very low. So I use laparoscopy to determine whether the patient responds or not. And for many of my patients, it seems to work. It's obviously a bit of an effort and it takes operating time. But I think I'm increasing my chances to make the right decision. So, coming back to your question about whether we should give three or six cycles, I think the current recommendations are three cycles pending the patient's response to neoadjuvant chemotherapy because my aim is to get a patient to R0 or at least minimal residual disease. Surgery is really, in this case, I think surgery is the adjunct to systemic treatment. Dr. Ebony Hoskins: Definitely. I think you make a great point, and I think the guideline just came out, like you mentioned, regarding neoadjuvant. And I think the biggest thing that we need to come across is the involvement of a gynecologic oncologist in patients with ovarian cancer. And we know that that survival increases with that involvement. And I think the involvement is the surgery, right? So, maybe we've gotten away from the primary tumor debulking and now using more neoadjuvant, but surgery is still needed. And so, I definitely want to have a take home that GYN oncology is involved in the care of these patients upfront. Dr. Andreas Obermair: I totally support that. This is a very important statement. So when I'm saying surgery is the adjunct to medical treatment, I don't mean that surgery is not important. Surgery is very important. And the timing is important. And that means that the surgeons and the med oncs need to be pulling on the same string. The med oncs just want to get the cytotoxic into the patients, but that's not the point, right? We want to get the cytotoxic into the patients at the right time because if we are working under this precision surgery, precision treatment mantra, it's not only important what we do, but also doing it at the right time. And ideally, I I would like to give surgery after three cycles of neoadjuvant chemotherapy, if that makes sense. But sometimes for me as a surgeon, I talk to my med onc colleagues and I say, “Look, she doesn't have a good enough response to her treatment and I want her to receive six cycles and then we re-evaluate or change medical treatment,” because that's an alternative that we can swap out drugs and treat upfront with a different drug and then sometimes they do respond. Dr. Ebony Hoskins:  I have maybe one more topic. In the area I'm in, in the Washington D.C. area, we see lots of endometrial cancer and they're not grade 1, right? They're high-risk endometrial cancer and advanced. So a number of patients with stage 3 disease, some just kind of based off staging and then some who come in with disease based off of the CT scan, sometimes omental caking, ascites. And the real question is we have extrapolated the use of neoadjuvant chemotherapy to endometrial cancer. It's similar, but not the same. So my question is in an advanced endometrial cancer, do you think there's still a role, when I say advanced, I mean, maybe stage 4, a role for surgery? Dr. Andreas Obermair: Most definitely. But the question is when do you want to give this surgery? Similar to ovarian cancer, in my experience, I want to get to R0. What am I trying to achieve here? So, I reckon we should do a trial on this. And I reckon we have, as you say, the number of patients in this setting is increasing, we could do a trial. I think if we collaborate, we would have enough patients to do a proper trial. Obviously, we would start maybe with a feasibility trial and things like that. But I reckon a trial would be needed in this setting because I find that the incidence that you described, that other people would come across, they're becoming more and more common. I totally agree with you, and we have very little data on that. Dr. Ebony Hoskins: Very little and we're doing what we can. Dr. Obermair, thank you for sharing your fantastic insights with us today on the ASCO Daily News Podcast and for all the work you do to advance care for patients with gynecologic cancer. Dr. Andreas Obermair: Thank you, Dr. Hoskins, for hosting this and it's been an absolute pleasure speaking with you today. Dr. Ebony Hoskins: Definitely a pleasure and thank you to our listeners for your time today. Again, Dr. Obermair's article is titled, “Controversies in the Surgical Management of Gynecologic Cancer: Balancing the Decision to Operate or Hesitate,” and was published in the 2024 ASCO Educational Book. And you'll find a link to the article 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. 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. Ebony Hoskins @drebonyhoskins Dr. Andreas Obermair @andreasobermair Follow ASCO on social media:       @ASCO on Twitter       ASCO on Bluesky   ASCO on Facebook       ASCO on LinkedIn       Disclosures:   Dr. Ebony Hoskins: No relationships to disclose. Dr. Andreas Obermair: Leadership: SurgicalPerformance Pty Ltd. Stock and Ownership Interests: SurgicalPerformance Pty Ltd. Honoraria: Baxter Healthcare Consulting or Advisory Role: Stryker/Novadaq Patents, Royalties, and Other Intellectual Property: Shares in SurgicalPerformance Pty Ltd. Travel, Accommodation, Expenses: Stryker    

Dr. John Sweetenham and Dr. James Foran discuss the evolving treatment landscape in acute myeloid leukemia, including new targeted therapies, advances in immunotherapy, and the current role for allogeneic transplantation. TRANSCRIPT Dr. John Sweetenham: Hello, I'm Dr. John Sweetenham, the host of the ASCO Daily News Podcast. There has been steady progress in the therapies for acute myeloid leukemia (AML) in recent years, largely based on an increasing understanding of the molecular mechanisms which underlie the disease. On today's episode, we'll be discussing the evolving treatment landscape in AML. We'll explore risk group stratification, new targeted therapies, advances in immunotherapy for AML, and also a little about the current role for allogenic transplantation in this disease.  I'm delighted to welcome Dr. James Foran to this discussion. Dr. Foran is a professor of medicine and chair of the Myeloid Malignancies and Blood and Marrow Transplant Disease Group at the Mayo Clinic Comprehensive Cancer Center. He's based in Jacksonville, Florida.  Our full disclosures are available in the transcript of this episode.  James, it's great to have you join us on the podcast today, and thanks so much for being here. Dr. James Foran: I'm delighted and thank you for the invitation. Thank you very much. Dr. John Sweetenham: Sure, James, let's get right into it. So, our understanding of the molecular mechanisms underlying AML has resulted not only in new methods for risk stratification in this disease, which have added refinement to cytogenetics, but also has resulted in the development of many new targeted agents. Understanding that this is a complex area of investigation, and our time is somewhat limited, can you give us a high-level update on the current state of the art in terms of how risk factors are being used for treatment selection now? Dr. James Foran: Absolutely. I think in the past, you know, we had things broken down pretty simply into make a diagnosis based on morphology, do cytogenetics, break patients into the groups of those who were more likely to benefit from therapy – so-called favorable risk – those where the intensive therapies were less likely to work – so-called poor adverse risk, and then this large intermediate group that really had variable outcomes, some better, some worse. And for a long time, the progress was in just identifying new subtle cytogenetic risk groups. And then, late 1990s, we began to understand that FLT3 mutations or NRAS mutations may be more adverse than others that came along. In the first part of this millennium, in the, you know, 2000-2010 range, a lot of work was being done to understand better or worse risk factors with single genes. The ability to do multiplex PCR, and then more recently NGS platforms, have allowed us to really look at many genes and identify many mutations in patients. At the beginning that was used just to sort of refine – who did a little better, who did a little worse with intensive therapy – helped us decide who may benefit more from an allogeneic transplanter for whom that would not be necessary.  But the good news is that really, we're now starting to target those mutations. One of the first molecularly targeted treatments in leukemia was FLT3 mutations, where we knew they were adverse. Then along came targeted treatments. I was involved in some of those early studies looking at sunitinib, sorafenib, more recently midostaurin, now quizartinib, FDA approved, and gilteritinib in the relapse refractory setting.  So we're moving into a state where we're not just refining prognosis, we're identifying targets. You know, it's been slow progress, but definite incremental progress in terms of outcomes by looking for FLT3 mutations, then looking for IDH mutations, and more recently, mutations involving NPM1 or rearrangement of what we used to call the MLL gene, now the lysine methyltransferase 2A or KMT2A rearrangement, where we now have targets. And it's not just for refinement of prognosis, but now we're identifying therapeutic targets for patients and ways to even look for measurable residual disease which is impacting our care. Dr. John Sweetenham: That's great, James. And I'm going to expand on that theme just a little bit and perhaps ask you to elaborate a little bit more on how the introduction of these new therapies have specifically impacted frontline therapy. And a couple of ancillary questions maybe to go along with that: First of all, is ‘7+3' a standard therapy for anybody in 2025? And maybe secondly, you know, could you comment also maybe briefly on older patients with AML and how you think maybe the treatment landscape is changing for them compared with, say, 5 or 10 years ago? Dr. James Foran: I'll start with the therapy and then work my way back. So we've had ‘7+3' cytarabine daunorubicin or cytarabine anthracycline since 1976, and we're still using it as the backbone of our intensive therapy. There is still an important role for it, particularly in younger or fitter patients, and particularly for those with intermediate or favorable risk genetic groups or cytogenetic risk groups just because we achieve high rates of remission. Our 30-day induction mortality rates are lower now than they were 10 and 20 years ago. Our supportive care is better. And we still have a busy inpatient hospital service here at Mayo Florida and my colleagues in Rochester and Arizona as well giving intensive therapy. So that remains the backbone of curative therapy for younger adults. We are trying to be a little more discriminating about who we administer that to. We are trying to add targeted agents. We know from, now, two different randomized trials that the addition of a FLT3 inhibitor, either midostaurin or more recently quizartinib, has a survival advantage in patients with a FLT3 mutation, or for quizartinib, a FLT3/ITD mutation. And so yes, ‘7+3' remains important.  Off protocol for somebody who just comes in with acute leukemia in a 40-year-old or 30-year-old or even early 60s and fit, we would still be considering ‘7+3' therapy and then waiting for an expedited gene mutation panel and an expedited cytogenetics panel to come back to help us discriminate is that a patient for whom we should be giving a FLT3 inhibitor? I think there's a little more nuance about when we do a day 14 bone marrow, do they really matter as much anymore? I still do them. Some of my colleagues find them less important. But we're still giving intensive therapy. We're still giving high-dose ARA-C consolidation for younger patients who achieve complete remission.  In older adults, it's a different story. You know, it was only in the early part of the 2000s – 2004, 2007 range – where we really got buy-in from randomized studies that low-dose therapy was better than no therapy. There was a lot of nihilism before then about therapy for older adults, especially over age 75. We know that low-dose ARA-C is better than nothing. It looked like azacitidine was better than ARA-C or at least equivalent or slightly better. But with the advent of venetoclax it was a game changer. I ran a national randomized study of intensive therapy in AML. It was the last national randomized study of intensive therapy in older patients right before venetoclax got approved. And we were very excited about our results, and we thought we had some really interesting clinical results. And suddenly that's a little bit obsolete in patients over 70 and particularly over age 75 because of the high remission rates with azacytidine venetoclax or hypomethylating agents, so-called HMAs and venetoclax and the survival advantage. Now, it's not a home run for everybody. We quote 60% to 70% remission rates, but it's a little different based on your cytogenetics and your mutation profile. You have to continue on therapy so it's continuous treatment. It's not with curative intent, although there are some people with long-term remission in it. And the median survival went from 10 months to 15 months. So home run? No, but definitely improved remissions, meaningful for patients off transfusions and better survival. So right now it's hard to find an older adult who you wouldn't give azacitidine and venetoclax or something similar, decitabine, for instance, and venetoclax, unless somebody really was moribund or had very poor performance status or some reason not to. And so ‘7+3' is still relevant in younger adults. We're trying to get better results with ‘7+3' by adding targeted agents and azacitine and venetoclax in older adults.  I think the area of controversy, I guess there are two of them, is what to do in that overlap age between 60 and 75. Should people in that age still get intensive therapy, which we've used for years – the VIALE-A trial of aza-venetoclax was age 75 plus – or with cardiac comorbidities? And I think if you're 68 or 72, many of us are starting to bias towards aza-venetoclax as generally being better tolerated, generally being more outpatient, generally being slow and steady way to get a remission. And it doesn't stop you from going to transplant for somebody who might still be a candidate.  The other area of controversy is somebody under 60 who has adverse cytogenetics where we don't do very well with ‘7+3,' we still give it and we might do just as well with decitabine venetoclax. A lot of us feel that there's equipoise in the 60 to 75 group where we really can ask a question of a randomized study. Retrospective studies might suggest that intensive therapy is a little better, but there are now a couple of randomized studies happening saying, “Can we replace ‘7+3' in that intermediate age with aza-venetoclax?” And for younger adults similarly, we're looking to see how we apply that technology. Those are the areas where we're really trying to investigate what's optimal for patients and that's going to require randomized trials. Dr. John Sweetenham: Oh, that's great, thank you. And I'll just extend that question a little bit more, particularly with respect to the new targeted therapies. How much are they impacting the treatment of these patients in the relapse and refractory setting now? Dr. James Foran: Oh, they're definitely impacting it. When I trained and probably when you trained, AML was still a medical emergency. But that was the thing that you admitted to the hospital immediately, you started therapy immediately. The rule was always that's the one thing that brings the fellow and the consultant in at night to see that new patient on a Friday or Saturday. Now, we'll still admit a patient for monitoring, but we try not to start therapy for the first three or five or seven days if they're stable, until we get those genetics and those genomics back, because it helps us discriminate what therapy to pursue. And certainly, with FLT3 mutations, especially FLT3/ITD mutations, we're adding FLT3 inhibitors and we're seeing a survival advantage. Now, on the surface, that survival advantage is in the range of 7% or 10%. But if you then pursue an allogeneic transplant in first remission, you're taking disease where we used to see 30%, 40% long-term survival, maybe less, and you're pushing that to 60%, 70% in some studies. And so we're now taking a disease that– I don't want to get off topic and talk about Ph+ ALL. But that's a disease where we're actually a little excited. We have a target now, and it used to be something really adverse and now we can do a lot for it and a lot about it.  The other mutations, it's a little more subtle. Now, who knew until 2010 that a mutation in a sugar metabolism gene, in isocitrate dehydrogenase, or IDH was going to be so important, or even that it existed. We know that IDH1 and IDH2 mutations are still a minority of AML, certainly less than 10% to 15%, maybe overall. But we're able to target those with specific IDH1 and IDH2 inhibitors. We get single-agent responses. There are now two approved IDH1 inhibitors on the market. We don't yet have the randomized data that adding those to intensive therapy is better, but we're getting a very strong hint that it might be better in older adults who have an IDH mutation, maybe adding those is helpful and maybe adding those to low-intensity therapy is helpful. Those studies are ongoing, and we're also trying with low-intensity treatments to add these agents and get higher remission rates, deeper remissions, longer remissions. I think a lot of work has to be done to delineate the safety of that and the long-term efficacy. But we're getting hints it's better, so I think it is impacting.  The other area it's impacting is when you pick up adverse mutations and those have crept into our classification systems like an ASXL1 mutation or RUNX1 mutation for instance, or some of the secondary AML mutations like BCOR and others, where that's helping us discriminate intermediate-risk patients who we think aren't going to do as well and really helping us select a group who's more likely to get benefit from allogeneic transplant or for whom at least our cure rates without allo transplant are low. And so I think it's impacting a lot. Dr. John Sweetenham: Great. And I'm going to pick up now, if I may, on a couple of things that you've just mentioned and continue the theme of the relapsed and refractory setting. We've started to see some reports which have looked at the role of immune strategies for patients with AML, in particular CAR T or NK cells. Can you comment a little on this and let us know whether you think either these two strategies or other immune strategies are likely to have a significant role in AML in the future? Dr. James Foran: They are, but I think we're still a step behind finding the right target or the right way to do it. If you think of allogeneic transplantation as the definitive immune therapy, and we know for adverse AML we can improve survival rates and cure rates with an allotransplant, then we know inherently that immune therapy matters. And so how do we do what they've done in large cell lymphoma or in CD19 targeting for B cell malignancies? How do we bring that to acute myeloid leukemia? There have been a number of efforts. There have been at least 50 trials looking at different targets. CD33, CD123, CD7, others, CLL-1. So, there have been a number of different trials looking at how to bind a CAR T or a CAR T construct that can be active. And we have hints of efficacy. There was kind of a provocative paper in the New England Journal of Medicine a year ago in April of last year from a Chinese group that looked at a CD7-based CAR T and it was 10 patients, but they used CD7 positive acute leukemia, AML or ALL and had a CD7-targeted CAR T and they actually incorporated that with a haploidentical transplant and they had really high remission rates. People tolerated it quite well. It was provocative. It hasn't yet been reproduced on a larger scale, but the strong hints that the strategy is going to work.  Now, CD33 is a little tricky to have a CAR T when CD33 is expressed on normal hematopoietic cells. CD123 likewise. That's been something where there's, I think, still promise, but we've struggled to find the trials that make that work. Right now, there's a lot of interest in leveraging NK cells and looking, for a couple of reasons, but NK cells are attractive and NK cell markers might be attractive targets. NK cells might have similar degrees of immune efficacy. It's speculative, but they are likely to have less cytokine release syndrome and less neurotoxicity than you see with CAR T. And so it's kind of attractive to leverage that. We have had some ongoing trials looking at it with bispecifics and there certainly are trials looking at it with CAR NK-based strategies. One of the antigens that people looked at is the NK group 2D. NK group 2D or NKG2D is overexpressed in AML and its ligands overexpressed. And so that's a particular potential target. So, John, it's happening and we're looking for the hints of efficacy that could then drive a pivotal trial to get something approved.  One of the other areas is not restricting yourself just to a single antigen. For instance, there is a compound that's looking at a multi-tumor-associated antigen-specific T-cell therapy, looking at multiple antigens in AML that could be overexpressed. And there were some hints of activity and efficacy and actually a new trial looking at a so-called multi-tumor associated antigen-specific T cell therapy. So without getting into specific conflicts of interest or trials, I do think that's an exciting area and an evolving area, but still an investigational area. I'll stop there and say that we're excited about it. A lot of work's going there, but I'm not quite sure which direction the field's going to pivot to there. I think that's going to take us some time to sort out. Dr. John Sweetenham: Yeah, absolutely. But as you say, exciting area and I guess continue to watch this space for now.  So you've mentioned allogeneic stem cell transplants two or three times during this discussion. Recognizing that we don't have an imatinib for AML, which has kind of pushed transplant a long way further back in the treatment algorithm, can you comment a little on, you know, whether you think the role of stem cell transplantation is changing in AML or whether it remains pretty much as it was maybe 10 years ago? Dr. James Foran: By the way, I love that you use imatinib as an introduction because that was 6 TKIs ago, and it tells you the evolution in CML and you know, now we're looking at myristoyl pocket as a target, and so on. That's a great way to sort of show you the evolution of the field.  Allogeneic transplant, it remains a core treatment for AML, and I think we're getting much smarter and much better about learning how to use it. And I'm just going to introduce the topic of measurable residual disease to tell you about that. So I am a little bit of a believer. Part of my job is I support our allogeneic transplant program, although my focus is acute myeloid leukemia, and I've trained in transplant and done it for years and did a transplant fellowship and all that. I'm much more interested in finding people who don't need a transplant than people who do. So I'm sort of looking for where can we move away from it. But it still has a core role. I'll sidestep and tell you there was an MDS trial that looked at intermediate or high-risk MDS and the role of allogeneic transplant that shows that you about double your survival. It was a BMT CTN trial published several years ago that showed you about double your three-year survival if you can find a donor within three months and get to a transplant within six months. And so it just tells you the value of allotransplant and myeloid malignancy in general. In AML we continue to use it for adverse risk disease – TP53 is its own category, I can talk about that separately – but adverse risk AML otherwise, or for patients who don't achieve a really good remission. And I still teach our fellows that an allotransplant decreases your risk of relapse by about 50%. That's still true, but you have to have a group of patients who are at high enough risk of relapse to merit the non-relapse mortality and the chronic graft versus host disease that comes with it. Now, our outcomes with transplant are better because we're better at preventing graft versus host disease with the newer strategies such as post-transplant cyclophosphamide. There are now new FDA-approved drugs for acute and chronic graft versus host disease, ruxolitinib, belumosudil, axatilimab now. So we have better ways of treating it, but we still want to be discriminating about who should get it.  And it's not just a single-minded one-size-fits-all. We learned from the MORPHO study that was published in the JCO last year that if you have FLIT3-positive AML, FLIT3/IDT-positive AML, where we would have said from retrospective studies that your post-transplant survival is 60% give or take, as opposed to 15% or 20% without it, that we can discriminate who should or shouldn't get a transplant. Now that trial was a little bit nuanced because it did not meet its primary endpoint, but it had an embedded randomization based upon MRD status and they used a very sensitive test of measurable residual disease. They used a commercial assay by Invivoscribe that could look at the presence of a FLT3/ITD in the level of 10 to the minus 5th or 10 to the minus 6th. And if you were MRD-negative and you went through a transplant, you didn't seem to get an advantage versus not. That was of maintenance with gilteritinib, I'll just sort of put that on there. But it's telling us more about who should get a transplant and who shouldn't and who should get maintenance after transplant and who shouldn't.  A really compelling study a year ago from I don't know what to call the British group now, we used to call them the MRC and then the NCRI. I'm not quite sure what to call their studies at the moment. But Dr. Jad Othman did a retrospective study a year ago that looked at patients who had NPM1 mutation, the most common mutation AML, and looked to see if you were MRD positive or MRD negative, what the impact of a transplant was. And if you're MRD negative there was not an advantage of a transplant, whereas if you're MRD positive there was. And when they stratified that by having a FLT3 mutation that cracked. If you had a FLT3 mutation at diagnosis but your NPM1 was negative in remission, it was hard to show an advantage of a transplant. So I think we're getting much more discriminating about who should or should not get a transplant by MRD testing for NPM1 and that includes the patients who have a concomitant FLT3 mutation. And we're really trying to learn more and more. Do we really need to be doing transplants in those who are MRD-negative? If you have adverse risk genetics and you're MRD-negative, I'll really need good data to tell me not to do a transplant, but I suspect bit by bit, we'll get that data. And we're looking to see if that's really the case there, too. So measurable residual disease testing is helping us discriminate, but there is still a core role of allogeneic transplant. And to reassure you, compared to, I think your allotransplant days were some time ago if I'm right. Dr. John Sweetenham: Yes. Dr. James Foran: Yeah. Well, compared to when you were doing transplants, they're better now and better for patients now. And we get people through graft versus host disease better, and we prevent it better. Dr. John Sweetenham: That's a great answer, James. Thanks for that. It really does help to put it in context, and I think it also leads us on very nicely into what's going to be my final question for you today and perhaps the trickiest, in a way. I think that everything you've told us today really emphasizes the fact that the complexity of AML treatment has increased, primarily because of an improved understanding of the molecular landscape of the disease. And it's a complicated area now. So do you have any thoughts on what type of clinical environment patients with AML should be evaluated and treated in in 2025? Dr. James Foran: Yeah, I want to give you a kind of a cautious answer to that because, you know, I'm a leukemia doctor. I work at a leukemia center and it's what we focus on. And we really pride ourselves on our outcomes and our diagnostics and our clinical trials and so on. I am very aware that the very best oncologists in America work in private practice and work in community practice or in networks, not necessarily at an academic site. And I also know they have a much harder job than I have. They have to know lung cancer, which is molecularly as complicated now as leukemia, and they have to know about breast cancer and things that I don't even know how to spell anymore. So it's not a question of competence or knowledge. It's a question of infrastructure. I'll also put a little caveat saying that I have been taught by Rich Stone at Dana-Farber, where I did a fellowship a long time ago, and believe Rich is right, that I see different patients than the community oncologists see with AML, they're seeing different people. But with that caveat, I think the first thing is you really want to make sure you've got access to excellence, specialized hematopathology, that you can get expedited cytogenetics and NGS testing results back. There was a new drug, approved just a few months ago, actually, for relapsed AML with a KMT2A rearrangement, revumenib. We didn't talk about the menin inhibitors. I'll mention them in just a second. That's a huge area of expansion and growth for us. But they're not found on NGS platforms. And normal cytogenetics might miss a KMT2A-rearrangement. And we're actually going back to FISH panels, believe it or not, on AML, to try to identify who has a KMT2A-rearrangement. And so you really want to make sure you can access the diagnostic platforms for that.  I think the National Referral Labs do an excellent job. Not always a really fast job, but an excellent job. At my institution, I get NGS results back within three days or four days. We just have an expedited platform. Not everybody has that. So that's the key, is you have to be able to make the diagnosis, trust the pathologist, get expedited results. And then it's the question of trying to access the targeted medications because a lot of them are not carried in hospital on formulary or take time to go through an insurance approval process. So that's its own little headache, getting venetoclax, getting gilteritinib, getting an IDH1 inhibitor in first line, if that's what you're going for. And so I think that requires some infrastructure. We have case managers and nurses who really expedite that and help us with it, but that's a lot of work. The other piece of the puzzle is that we're still with AML in the first month and maybe even the second month. We make everybody worse before we make them better. And you have to have really good blood bank support. I can give an outpatient platelet transfusion or red cell transfusion seven days a week. We're just built for that. That's harder to do if you're in a community hospital and you have to be collaborating with a local blood bank. And that's not always dead easy for somebody in practice. So with those caveats, I do find that my colleagues in community practice do a really good job making the diagnosis, starting people on therapy, asking for help. I think the real thing is to be able to have a regional leukemia center that you can collaborate with, connect with, text, call to make sure that you're finding the right patients who need the next level of diagnostics, clinical trial, transplant consults, to really get the best results.  There was some data at ASH a couple of years ago that looked at – the American Society of Hematology and ASCOs had similar reports – that looked at how do we do in academic centers versus community practice for keeping people on therapy. And on average, people were more likely to get six cycles of therapy instead of three cycles of therapy with azacitidine venetoclax at an academic center. Now, maybe it's different patients and maybe they had different cytogenetics and so on, but I think you have to be patient, I think you have to collaborate. But you can treat those patients in the community as long as you've got the infrastructure in place. And we've learned with virtual medicine, with Zoom and other platforms that we can deliver virtual care more effectively with the pandemic and beyond. So I think we're trying to offer virtual consults or virtual support for patients so they can stay in their home, stay in their community, stay with their oncologists, but still get access to excellent diagnostics and supportive care and transplant consults, and so on. I hope that's a reasonable answer to that question. It's a bit of a nuanced answer, which is, I think there's an important role of a leukemia center, and I think there's a really fundamental role of keeping somebody in the community they live in, and how we collaborate is the key to that. And we've spent a lot of time and effort working with the oncologists in our community to try to accomplish that.  John, I want to say two other things. I didn't mention in the molecular platforms that NPM1 mutations, we can now target those on clinical trials with menin inhibitors. We know that NPM1 signals through the Hoxa9/Meis1 pathway. We know that similar pathways are important in KMT2A rearrangements. We know that there are some other rare leukemias like those with NUP98 rearrangement. We can target those with menin inhibitors. The first menin inhibitor, revuminib, was approved by the FDA for KMT2A. We have others going to the FDA later this year for NPM1. There are now pivotal trials and advanced expanded phase 1/2 studies that are showing 30% response rates. And we're looking to see can we add those into the first-line therapy. So, we're finding more targets.  I'll say one last thing about molecular medicine. I know I'm a little off topic here, but I always told patients that getting AML was kind of like being struck by lightning. It's not something you did. Now, obviously, there are risk factors for AML, smoking or obesity or certain farm environments, or radioactive exposures and so on. But bit by bit, we're starting to learn about who's predisposed to AML genetically. We've identified really just in the last five or eight years that DDX41 mutations can be germline half the time. And you always think germline mutations are going to cause AML in a younger patient, but the median age is 60 to 70 just like other AMLs. They actually might do pretty well once they get AML. We've reported that in several papers. And so we're trying to understand who that has a RUNX1 mutation needs germline testing, who with a DDX41 needs germline testing. And we're trying to actually come up with a cleaner pathway for germline testing in patients to really understand predisposition, to help with donor selection, to help with family counseling. So I think those are other areas where a leukemia center can contribute for somebody in who's community practice to understand genomic or genetic complexity in these patients. And we're starting to develop the databases that support that. Dr. John Sweetenham: Yeah, great. Thanks, James. I loved your answer about the clinical environment too. And I know from a patient-centric perspective that I know that patients would certainly appreciate the fact that we're in a situation now where the folks taking care of them will make every effort to keep them close to home if they possibly can.  I want to thank you, James, for an incredible review of a very complex subject and I think you did a great job. I think we all will have learned a lot. And thanks again for being willing to share your insights with us today on the ASCO Daily News Podcast. Dr. James Foran: John, it's my pleasure. And as you know, I'll do anything for a latte, so no problem at all. Dr. John Sweetenham: Okay. I owe you one, so thank you for that.  And thank you to our listeners for your time today. You'll find links to the studies we've discussed today in the transcript of this episode. And 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. John Sweetenham  Dr. James Foran 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. James Foran: Stock and Other Ownership Interests: Aurinia Pharmaceuticals Consulting or Advisory Role: Peerview, CTI BioPharma Corp, Remix Therapeutics, Cardinal Health, Medscape, Syndax, Autolus Therapeutics Research Funding (Inst.): Chordia Therapeutics, Abbvie, Actinium Pharmaceuticals, Kura Oncology, Sellas Life Sciences, Novartis, Roivant, Celgene/Bristol-Myers Squibb, Astellas Pharma, SERVIER Travel, Accommodations, Expenses: Peerview

JCO PO author Dr. Hatim Husain at University of California San Diego, shares insights into his JCO PO article, “Adagrasib Treatment After Sotorasib-Related Hepatotoxicity in Patients With KRASG12C-Mutated Non–Small Cell Lung Cancer: A Case Series and Literature Review”, one of the top downloaded articles of 2024. Host Dr. Rafeh Naqash and Dr. Husain discuss how to utilize real-world and clinical trial data to discern the safety of adagrasib (another KRASG12C inhibitor), following sotorasib discontinuation due to hepatotoxicity. 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 JCOPO articles. I'm your host, Dr. Rafeh Naqash, Podcast Editor for JCO Precision Oncology and Assistant Professor at the OU Stephenson Cancer Center.  Today, I'm very excited to be joined by Dr. Hatim Hussain, Professor of Medicine at the University of California, San Diego, and author of the JCO Precision Oncology article, “Adagrasib Treatment After Sotorasib-Related Hepatotoxicity in Patients With KRAS-G12C-Mutated Non-Small Cell Lung Cancer: A Case Series and Literature Review.” This was one of the top downloaded articles of 2024. And the other interesting thing is we generally don't do podcasts for case reports or case series, so this is one of the very few that we have selected for the podcast.  And at the time of the recording, our guest disclosures will be linked in the transcript.  Dr. Hussain, welcome to our podcast and thank you for joining us today. Dr. Hatim Husain: Thank you Dr. Naqash. Such a pleasure to be here and to speak with you all. Dr. Rafeh Naqash: And for the sake of this podcast, we'll refer to each other using our first names. So again, as I mentioned earlier that this is one of the very few case reports that we have selected for podcasts in JCOPO and the intention was very deliberate because it caters to something that is emerging where we are trying to treat more KRAS mutant patients with different KRAS inhibitors. And you tried to address one very unique aspect of it in this article which pertains to toxicity, especially hepatotoxicity. So for the sake of our listeners who tend to be community oncologists, trainees, academic faculty, can you tell us what are KRAS inhibitors? What is KRAS-G12C? And how do some of these approved KRAS inhibitors try to inhibit KRAS-G12C? Dr. Hatim Husain: Sure. For a long time actually we've not had a selective way to inhibit mutant KRAS. And over the last several years actually now, we've seen some dramatic advances here, particularly with the FDA approval of some of the selective inhibitors against the G12C variant. So KRAS-G12C is an isoform of KRAS that is most common in lung cancer and in fact actually is a transversion mutation in the KRAS gene that is a product of the carcinogen of tobacco. And in fact, the incidence of KRAS-G12C in lung cancer, it's quite astounding where as many KRAS-G12C patients there are, there can be, as you know, more than EGFR patients in certain populations and cohorts. The medicines sotorasib and adagrasib were rationally designed to be selective KRAS-G12C inhibitors. And the way that they do this is that they lock the KRAS protein in the OFF state. KRAS is a protein that oscillates between an ON and an OFF state and by virtue of locking the protein in an OFF state, it has shown inhibition of downstream signaling and mitigation of tumor growth and, in fact, tumor cell death. Dr. Rafeh Naqash: I absolutely love the way you describe the ON and OFF state, the oscillation where the ON is bound to the GTP and the OFF is bound to the GDP. The two KRAS inhibitors as currently FDA approved, as you mentioned, are RAS OFF inhibitors and they're emerging KRAS inhibitors that are RAS ON. So now, as we have known from previous data related to immunotherapy and EGFR TKIs such as osimirtinib where toxicity tends to be a compounded effect when you have osimertinib given within a certain timeline of previous checkpoint therapy, we've seen that in the clinic as the data for these KRAS inhibitors is emerging, you talk about some very interesting aspects and data about what has been published so far with regards to prior use of immunotherapy or chemo immunotherapy and the subsequent use of KRAS inhibitors. Could you elaborate upon that? Dr. Hatim Husain: Sure. So for this population of patients, the first line approved strategy is a strategy that most cases will incorporate immune therapy and chemotherapy. Immune therapy can have some important responses for patients with KRAS-G12C. This may be due to the fact that KRAS-G12C patients may have a higher incidence of prior smoking, perhaps higher mutation burdens in some patients, and perhaps immunogenicity is defined in that context. So the standard of care in the first line currently includes immune therapy or immune therapy and chemotherapy. Where the current FDA approvals for selective G12C inhibitors are are after the first line of therapy. There are a number of trials exploring these medicines in the first line to see if they may be incorporated into a future treatment paradigm. Dr. Rafeh Naqash: Thank you for that explanation. Now, going to what you published in this manuscript, can you help us understand the context of why you looked at this? Even though the data just comprises a case series of a handful of patients, but the observations are very interesting and these are real world scenarios where we often tend to be in situations where an individual has had toxicity on a certain drug and may have some response to that drug, but at the same time, the toxicity is challenging. And then you try to debate whether another drug in the same class might be beneficial without those toxicities. So you've tried to address that to some extent using this data set. So can you elaborate upon the question, the methodology, what you tried to look at, and important observations that you have? Dr. Hatim Husain: Yes, our paper was actually inspired by one of my patients. My patient was a patient who had received chemotherapy and immune therapy and actually in the past, even, you know, additional lines of immune therapies, it was really coming to the edge of where standard treatments would exist. It was right at the same time that these selective inhibitors had been approved and the patient had received sotorasib. And what was remarkable was, when given sotorasib, patient had a very high peak and spike in the transaminases. And we would do different trials of strategies around dose, around interruptions. And it was becoming quite difficult, actually, for the patient to proceed with additional therapy. It was around similar times, actually, and I do want to make a note that the patient was progressing, driven in large fact by the fact that we've had to interrupt the medicine. So we feel and believe that the patient had had inadequate dosing because of the level of toxicity that the patient was having with transaminase increase. So it was around the same time that adagrasib was first commercially available that we were at that point, and we did a trial of adagrasib post-sotorasib, largely driven by necessity, without having additional options to provide this patient in our environment. What was remarkable was when the patient received the adagrasib, there were no spikes in transaminases similar to what we had seen before. And that really led us thinking and to say, “Is this adverse event of transaminase increase or hepatotoxicity, is this a class effect with KRAS-G12C inhibitors, or is it more nuanced than that? Are there different, perhaps, mechanisms by which the medicines may work that may more or less differentially contribute to this adverse event?” And so that inspired us to kind of do a larger analysis, kind of really reach out to a larger network of physicians to gather insights and to gather responses in patients who had had a serial approach of sotorasib and then adagrasib.  What we found in this process was, in fact, actually there were many more cases of patients who resembled my patient, where the sequence of sotorasib going to adagrasib may have demonstrated differential contribution of hepatotoxicity in that context. And that really motivated us to put the publication together to due diligence, and in the publication spend a lot of time to kind of outline each patient case in detail around metrics surrounding time from last immune therapy, the number of days on sotorasib, the best response to sotorasib, the interval between sotorasib and adagrasib, the duration of adagrasib and then the grade of hepatotoxicity seen in each of the contexts, and particularly kind of the adagrasib and patient disease status as well. We were quite inspired by the effort to try to, if we do not have randomized data in comparison of one medicine to another, which we do not at this juncture, we do not have a randomized analysis to really diligently and rigorously compare the rates of AEs across each medicine, and even in sequence, we do not have that with immune therapy. But what we felt was trying to get more analysis of this sequential approach of, if patients had received a medicine, had to be taken off because of toxicity and then actually tried on a new medicine, what were those rates? We felt like that was at least some information to try to get at this question. Dr. Rafeh Naqash: And you bring forward a very important point, which is, a lot of times in the real world setting we don't have cross trial comparisons that can be fully applicable, or we don't have trials that compare two drugs of the same class with respect to the AE profile or efficacy. And observations like the one that you described that led to this study are extremely critical in trying to help answer these questions.  From a data standpoint, and you allude to it to some extent in your manuscript, the trials that are trying to address combination of KRAS-G12C with immunotherapy, especially sotorasib or adagrasib, can you elaborate on that data, what has been published so far and summarize it for our listeners? Dr. Hatim Husain: So there is data from clinical trials looking at patients actually who have received concomitant immune therapy and sotorasib. What was seen in this, in a real world analysis, was that some patients actually who had received sotorasib within a close proximity of immune therapy, as well as a larger study actually which showed in combination there were higher rates of hepatotoxicity in that context. In fact, there were rates of grade 3 hepatotoxicity. And I think built upon that data there's a recognition in the field that we have to be very diligent in terms of even the clinical trial designs in how to understand the pairing between immune therapy and selective G12C inhibitors. There are many trials that are ongoing, one of the studies that is ongoing is known as the KRYSTAL-7 study, which is evaluating adagrasib in combination with pembrolizumab in the first line. And we await more information on that strategy as well. In the context of sotorasib, because of some of the trials that have shown higher rates of hepatotoxicity, there are some additional trials now looking at sotorasib in combination with chemotherapy, and those also have some information that have been reported as well. Dr. Rafeh Naqash: From a drug development standpoint, as you mentioned, there's always a tendency to combine something with something else. And in my practice, and I'm sure in your practice too, when we do early phase trials, many trials are still focused on choosing the maximum tolerated dose, which may be something that we need to gradually move away from as we try to implement these combinations of multiple antibodies plus some of these target agents from maybe the biological optimal dose rather than the maximal tolerant dose is a better way to look at the drugs, the pharmacokinetic profile, and then see what is likely the safest combination with the most appropriate target engagement. Do you have any thoughts on that or insights on that from a drug development perspective? Dr. Hatim Husain: It's a wonderful question and I think it is a very insightful question and understanding of where we are in space right now. And I agree with you that historically, cancer drug development was really hinged upon medicines that perhaps required higher doses to see a benefit or to inch out kind of marginal increases upon where we were at. Now, in combination with medicines that have non-overlapping mechanisms of action, the concept is: Can there actually be more synergy across an approach using combinatorial strategies rather than just additive effects? And I think that in some cases this is being studied with immune therapy, in some cases actually even in the context of other novel mechanisms for cancer therapy. I think that in my practice, I will really try to see how a patient at an approved dose will respond. But definitely I'm open to the concept that there may be a dose that doesn't have to be the maximally tolerated dose, but rather the dose that responses can be seen and perhaps actually at a lower dose than what drives many toxicities. Dr. Rafeh Naqash: I often describe this to my patients as individual patient dose optimization outside of a clinical trial, where I'm sure you've probably done this, where in older adults maybe a lower dose of osimertinib is tolerated better, or a lower dose of sotorasib or adagrasib for that matter, tolerated better with perhaps a similar level of efficacy, since we don't have comparisons between doses and efficacy so far.  So I think in the bigger picture, as we discussed in a nutshell, what I would really like the listeners to understand is as we try to move towards this field of precision medicine targeting more and more of the undruggable genes, there's bound to be a certain level of toxicity patterns that we'll start observing. So I think these real world scenarios which may not be addressed using clinical trials because it is in the real world setting where you cycle one treatment after another after another, which may or may not be allowed in most trials and the real world setting can inform, in certain cases, subsequent trial designs. So I think the most important message, at least that I took from your manuscript, was that these real world observations can make a huge difference and inform practice, even though the data sets may be small. Of course, you want to validate some of these findings in a bigger, broader setting, but proof of concept is there. And I think next time I see an individual in my clinic where I see better toxicity, I'll definitely try to talk to them about subsequent treatment with another KRAS inhibitor, maybe adagrasib or something else, if and when appropriate.  Do you have any closing thoughts on some of these things that we discussed? Dr. Hatim Husain: I just want to leave the audience actually with this concept that sometimes we group targeted therapy side effects as being class effects unanimously. And I do think actually that each inhibitor may have different off target effects on where medicine may act. We don't truly understand the mechanism of hepatotoxicity in the context of selective KRAS-G12C inhibitors. One of the hypotheses may be due to off target cysteine reactivity in the numerous off target binding sites that certain medicines may have over others. And just even qualitatively which off target binding sites there may be, and how that may lead to either immunogenic responses and other organs or such. So I do think that we do need more research to understand the mechanism. But I think where we are at right now in this space is not assuming that all medicines are going to have the exact same toxicity. I think especially when patients may not have other options, this is something to consider as well. Dr. Rafeh Naqash: Thank you so much. Now, outside of the scientific insights, Hatim, I know you a little bit from before. And knowing the kind of work that you've done in precision medicine, I'm really interested to know about where you started, how you started, how things have been, and what kind of advice you have for junior faculty fellows who are interested in this field of precision medicine that is becoming more and more exciting as we progress in the oncology space. Dr. Hatim Husain: Thank you, Rafeh. I will say, actually as a medical student, I was actually very interested in oncology, partly because it was then and still remains one disease or a constellation of diseases that just has such a high psychological burden on patients. And through the experiences I've had, I really can understand and relate with that concept. I did my medical school at Northwestern, residency at the University of Southern California, and then my oncology fellowship at Johns Hopkins University.  And now I've been on faculty at University of California, San Diego, for about 12 years now. It's been a great experience paralleled with the fact that during these last 12 years, I've really seen how the developments in precision oncology, both targeted therapy as well as immune therapy, have really blossomed and unfolded. A large area of my research in my career has kind of focused on cancer genome and integration of novel technologies to really see how they may have clinical application. When I was in my fellowship and as a young faculty, the liquid biopsy was actually coming into development. And this was hinged upon information that had come forward in the prenatal space where some patients actually who were undergoing prenatal testing during pregnancy were found to have complex karyotypes and genomic alterations and then retrospectively found to have cancer.  And doing my fellowship at Johns Hopkins, some of the pioneers in liquid biopsy were my mentors and really kind of instilled in me that passion for really thinking through how cancer genomics can be integrated through time. And some of the research that I have been doing has been looking at clonal evolution of cancer, how cancer is changing over time, and how we can think through the right surveillance strategies to really understand how that change is occurring. The dynamics of ctDNA in retrospective cohorts have been studied and shown that, you know, there can be associations between progression-free survival and other clinical endpoints. The current paper that we are speaking about parallels that in a certain way where, rather than say, looking at clonal evolution and say, the efficacy answer of sotorasib first and then adagrasib and how frequently can adagrasib salvage patients, this looks at it from a different angle around toxicity. And I think that is a key point because, at my core, I really do enjoy the clinical aspect of complex decision making on behalf of patients weighing efficacy and toxicity that they may have as they try to get the best quality of life through this journey. Dr. Rafeh Naqash: Thank you again, Hatim, for all those insights, both from the scientific perspective as well as personal perspective. We appreciate that you chose JCOPO as the destination for your work.  And 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 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. Dr. Hatem Husain Disclosures Consulting or Advisory Role: AstraZeneca, Foundation Medicine, Janssen, NeoGenomics Laboratories, Mirati Speakers' Bureau: AstraZeneca, Janssen Institution Research Funding: Pfizer, Bristol-Myers Squibb, Regeneron, Lilly Travel, Accommodations, Expenses: AstraZeneca, Janssen, Foundation Medicine  

Host Dr. Shannon Westin and guests Dr. Bill Aronson discuss the article "High Omega-3, Low Omega-6 Diet With Fish Oil for Men With Prostate Cancer on Active Surveillance: The CAPFISH-3 Randomized Clinical Trial" and how Omega-6 are predominant in the American diet while the study significantly lowered the intake of Omega- 6 fats. TRANSCRIPT  Dr. Shannon Westin: Hello everyone and welcome to another episode of JCO After Hours, the podcast where we get in depth on manuscripts published in the Journal of Clinical Oncology. I'm your host, Dr. Shannon Westin, GYN Oncologist by trade and one of the grateful Social Media Editors of the JCO. And I am very excited to welcome a special guest today, Dr. William Aronson. He is professor of Urology in the UCLA Department of Urology, the Chief of Urology at Olive View UCLA Medical Center, and Chief of Urologic Oncology at the Veterans Administration West Los Angeles. Welcome, Dr. Aronson. Dr. William Aronson: Thank you, Shannon, and delighted to be here. Dr. Shannon Westin: We are so excited to have you discussing your manuscript, “High Omega-3, Low Omega-6 Diet With Fish Oil for Men With Prostate Cancer on Active Surveillance: The CAPFISH-3 Randomized Clinical Trial,” which was published in the Journal of Clinical Oncology on December 13, 2024. So let's get right to it. First of all, you know we have a very mixed audience, so can you just level set for us and speak about the population you studied in this important trial - that low risk, favorable, intermediate risk prostate cancer. How common is that? How is it defined? That would really help. Dr. William Aronson: I would say about 50% of the patients that we diagnose with prostate cancer either have low risk disease or what we call favorable intermediate risk disease. So when the pathologists look at the cancer under the microscope, they assign what's called a Gleason grade. Grade 3 is the slower growing type of prostate cancer, grade 5 is the fastest growing type, and grade 4 is somewhere in between. So a low risk group would be only the grade 3, the slower growing type. And the favorable intermediate risk group would actually be the grade 3+4, which means they mostly see the low risk type in there, but they also see the slightly faster growing type, grade 4. So this is what we typically see. We see these patients on a very regular basis when they're newly diagnosed with prostate cancer. Dr. Shannon Westin: Okay, got it. And then can you walk us through just what the management options are typically for this patient population? Dr. William Aronson: So typically for what we call the low risk group, the patients with a low PSA and only that grade 3 type, slower growing type of prostate cancer, the standard recommendations are active surveillance. So typically, we'll periodically monitor these patients with PSA blood testing and periodically do prostate biopsies depending upon the patient's other medical problems. Dr. Shannon Westin: So I think it would also be really helpful just to understand what your typical management options are for this patient population. Dr. William Aronson: So for patients with low risk prostate cancer, they only have the Gleason Grade 3+3 with a low PSA. The standard practice is observation. And so these men will periodically see them and measure their PSA values. And periodically, they'll undergo prostate biopsy to make sure they're not getting progression of their disease. For men with favorable intermediate risk prostate cancer, that's a little different. In some practices, the patient and the urologist will decide to do active surveillance. In other scenarios, these patients will definitely elect treatment, either with radical prostatectomy or radiation therapy or other treatments that are available. Dr. Shannon Westin: So your manuscript notes that there was a high level of interest in dietary supplements and approaches among patients with prostate cancer that do elect for active surveillance. Prior to the results of CAPFISH-3, did we have any data to support those types of recommendations? Dr. William Aronson: We actually don't have any long term prospective randomized trials that support that recommendation. There have been a number of very interesting epidemiologic studies, for example, suggesting maybe a plant-based diet might be helpful. Or a number of other studies suggesting maybe more tomato-based products like tomato sauces or tomato paste may be helpful. But no prospective longer term randomized trials that were positive. Dr. Shannon Westin: Okay, that makes sense. So what led you all to explore the high omega-3, low omega-6 fatty acid diet in this trial? Dr. William Aronson: After our initial omega-6 studies, we subsequently did some studies where we raised the omega-3 from fish oil and lowered the 6, looking at a more favorable ratio of the omega-3 to omega-6. And once again, we found that in our animal models, there was a significant delay in progression of prostate cancer. That then led us to perform a clinical trial. It was a short term trial in men prior to undergoing radical prostatectomy. And in these men, they were randomly assigned to one of two groups, either a western high fat diet or a low fat diet with fish oil. And we found after just four to six weeks, a significant change in the Ki67 level in their radical prostatectomy tissue. And Ki67 is actually a strong indicator of prostate cancer progression, spread, or even death from prostate cancer. Dr. Shannon Westin: Well, and I think that leads us really nicely into the design of the current study. So why don't you walk us through how CAPFISH-3 was designed. And you've already spoken a little bit about your primary endpoint. Dr. William Aronson: Based on the results of what we saw in the lab and what we saw in our short term clinical trial, we decided to perform a one year trial, a longer term trial in men on active surveillance. And these men were randomly assigned to either a diet with slight reduction in dietary fat, specifically reduction in the omega-6 intake as well as increase in foods with omega-3 and fish oil capsules. The other group, we asked the men to just not take fish oil capsules, but they could eat whatever else they wanted during the course of the study. Men in the diet where we lowered the omega-6 and raised the omega-3, they were seen by a dietitian once a month to really ensure that they were compliant with that intervention, which they were. The other intriguing part of our study, which I think is super important, is the precision that was used when these men underwent prostate biopsy. So, at baseline and at one year, when these men underwent prostate biopsy, they had the same site within the prostate biopsied. That's important because it's not so easy to find the same site within the prostate because of heterogeneity throughout the prostate. And so we were able to obtain that high level of precision as they were in an active surveillance program at UCLA with Dr. Leonard Marks. Dr. Shannon Westin: So we spoke a little bit about what's important about the Ki67 index as your primary endpoint. Can you talk a little bit about what the study found with your intervention? Dr. William Aronson: So we found that the Ki67 index increased by 24% in the control group and decreased by 15% in the low omega-6, high omega-3 group with fish oil capsules. So that ended up resulting in a statistically significant change between the groups favoring the low omega-6, high omega-3 group. Dr. Shannon Westin: And then what were the secondary endpoints that CAPFISH-3 explored? Anything of note that you want to review for the listeners? Dr. William Aronson: So a number of positive secondary endpoints from the trial. Firstly, we saw that the triglyceride levels were lower, which is what can typically be seen with omega-3 intake. We also saw reduced levels of a cytokine, a circulating factor in the bloodstream called ‘macrophage colony stimulating factor'. And that's particularly interesting because there's a certain type of macrophage which is well known to be involved in prostate cancer progression in men with more advanced prostate cancer, and we've been able to inhibit that in our animal models and in our tissue culture studies. And it was especially interesting to see that we did have an effect on this particular cytokine in this prospective randomized trial. We did not see changes in a number of other measures, including Gleason grade or PSA. These are measures that we use in clinical practice. To see an effect on those would have required a longer term and larger study to be performed. Dr. Shannon Westin: That makes sense. I think it's always great to try to get as much of these types of translational data as we can. But sometimes you just have to do what is reasonable and you get what you get. It looks to me like this regimen was fairly well tolerated. Did you obtain any patient reported outcomes or feedback on the trial? Dr. William Aronson: So, there were four patients in the fish oil group that did have some side effects, and we withdrew them from the study. They did have some effects on their upset stomach, and a number of men also had some diarrhea as well. And so for those four patients, we did withdraw them from the study. Dr. Shannon Westin: And then I guess the last question I have is really, what's next for this intervention? Are we ready to move this to the clinic or what do you see as next steps? Dr. William Aronson: Well, this next step that we're working on right now is to better understand exactly what happened in these patients. So we have blood, we have tissue, we're doing genetic studies on these patients. So that's really the first step, in our mind, to better understand what happened before moving to the next step. I'm particularly intrigued about trying this intervention in men with more advanced prostate cancer, specifically because of what we see, this particular diet and how it's affecting the patient's immune system and how that may favorably affect their course of their prostate cancer. Dr. Shannon Westin: Well, great. Well, thank you so much for taking the time to chat with us about such an important clinical trial, and I really appreciate all the work you're doing and hope to get to see you soon. Dr. William Aronson: Well, thanks for having me, Shannon. It's really an exciting finding and I think it's something that clinicians and patients are going to be super interested in. Dr. Shannon Westin: We love straightforward interventions that actually make a difference, so you guys are to be congratulated for that. And I just want to thank all of you for listening. Thanks again, and I hope you enjoyed this episode of JCO After Hours. Be sure to check out our other podcast offerings wherever you get your podcasts. Have an awesome day.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Dr. Aronson Disclosures: Stock and Other Ownership Interests Johnson and Johnson Speakers' Bureau Company name: Janssen Oncology, Bayer, Blue Earth Diagnostics, AstraZeneca, Pfizer/Astellas Research Funding: Lantheus Medical Imaging UCLA Health Article Video

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)  

In the latest episode of the Dads with Daughters podcast, we had a heartfelt and enlightening discussion with Kevin Lavelle, co-founder and CEO of Harbor. Kevin shared his experiences and reflections on raising two healthy children—an 8-year-old son and a 6-year-old daughter—while managing the demands of a thriving career. Kevin emphasized the importance of being present for his children despite the time constraints of being an entrepreneur. He has found fulfillment in volunteering as a soccer coach for his son and accompanying his daughter to gymnastics. His philosophy of being "appropriately selfish" underscored the necessity of self-care to be effective in caring for one's family. The Fleeting Nature of Childhood Both Kevin and our host, Dr. Christopher Lewis, resonate on how quickly time passes with young children. Recounting poignant moments like the birth of his son and profound moments in his entrepreneurial journey, Kevin appreciated the urgency of cherishing every moment with family. He shared a personal anecdote about working on a term sheet in the delivery room, highlighting the blend of work and personal life that many modern parents experience. This understanding deepened after a personal loss—his wife's mother—which reinforced the irreplaceable value of family time. Dr. Lewis echoed this sentiment, encouraging fathers to prioritize building strong relationships with their children over work commitments. Challenges of Modern Parenting Kevin tackled the complex challenge of raising respectful and capable children in today's world. He discussed the necessity of discipline, the influence of external factors such as peers and media, and the struggle of maintaining different parenting standards than others. Kevin and his wife take pride in their children's respectful behavior in public, yet they find themselves constantly correcting behaviors influenced by their environments. Dr. Lewis and Kevin also explored the concept of “deprogramming,” or correcting behaviors developed when children are outside the home. This underscores the dynamic landscape parents must navigate to maintain their values. Promoting Healthier Families Through Better Sleep A significant portion of the podcast focused on Kevin's venture, Harbor, which aims to improve parental well-being through better sleep. Inspired by his own experience with sleep deprivation, Kevin developed a product integrating professional guidance and innovative technology. The system offers a reliable baby monitoring solution, avoiding common issues with existing products, and introduces a concept of a remote night nanny service. This service is designed to be affordable and leverages professionally trained nurses to help parents manage nighttime challenges, ensuring better sleep for all family members. Fatherhood's Essential Bonds Kevin concluded by sharing his views on fatherhood—emphasizing a connection, love, and support as the bedrock of raising well-rounded children. He credited his own parents, his wife, and his children as his inspiration, and he offered advice to fellow fathers: Enjoy spending time with your children and cherish the fleeting nature of childhood. Parents today face numerous challenges, but as Kevin's journey illustrates, with mindfulness, appropriate self-care, and innovative solutions, the joys of parenting can indeed be balanced with professional success. For those seeking additional support, the podcast encourages engagement with resources like the Fatherhood Insider and the Dads with Daughters community. For Fathers, By Fathers: A Beacon of Support Dads with Daughters remains committed to helping fathers navigate the beautiful complexities of raising daughters to be strong, independent women. Tune in for more inspiring stories and practical advice from fathers like Kevin Lavelle.   TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:15]: Welcome back to the Dads with Daughters podcast where we bring you guests to be active participants in your daughters' lives, raising them to be strong, independent women. Really excited to have you back again this week. As always, every week, I love being on this journey with you. You and I are walking on this path to help our daughters to be those amazing women that we want them to be as they get into their adult years, and it's a process. It's definitely a process that we walk through to be able to be that dad that we wanna be and to be engaged and to be present and to be there for our daughters as they get older. And you don't have to walk that alone. That's why this podcast exists. It's here to help you to walk alongside other fathers that are either going through the process right now, have gone through the process, or other individuals that have resources that can help you again to be that dad that you wanna be. Dr. Christopher Lewis [00:01:12]: Every week, I love being able to bring you different guests, different people with different experiences that are fathering in different ways. And today, we got another great guest. Kevin Lovell is with us today, and Kevin is the cofounder and CEO of Harbour. It is a company that we're gonna learn more about today. But I love their tagline, we create happier parents and healthier families one restful night at a time. And how many of you remember, especially those young first few years when you felt like a zombie? I'm just going to put it plainly, and you felt like you were not getting any sleep, and probably you weren't getting a lot of sleep. But we're going to talk about this venture that he has been on for the last few years and what he's doing. But first 1st and foremost, we're gonna learn about him as a dad. Dr. Christopher Lewis [00:01:58]: So I'm really excited to have him here. Kevin, thanks so much for being here. Kevin Lavelle [00:02:01]: Thank you. A great opportunity. Dr. Christopher Lewis [00:02:02]: Well, Kevin, it's my pleasure having you here today. And one of the things that I love doing first and foremost is turning the clock back in time. And I know you've got 2 kids. We're gonna focus on your daughter today, but I know you've got a son as well. You got an 8 year old son and a 6 year old daughter. So you had your son first. Now I wanna go back to that first moment that you found out that you were going to be a father to a daughter. What was going through your head? Kevin Lavelle [00:02:26]: Really fun memory. My my wife and I, our son was a little over I don't know. He was maybe 16 months old when we found out we were going to have another child, and we both did that thing. And and I think we meant it. Then we said, you know, whether it's a boy or a girl, it doesn't matter. We're just gonna be so happy that, you know, have another. And to each their own, I wasn't into a big gender reveal party, but I did think it would be fun to learn together. And so we had her doctor email the results to someone on my team at Mizzen and Maine, and I asked him to go get flowers, you know, pink for a girl, blue for a boy, and put them in our garage so that when I came home, I was traveling, I could bring the flowers covered in a trash bag into the house and we could look at them together because my wife loves flowers. Kevin Lavelle [00:03:14]: That was the way that we were gonna learn together. And right as I was about to pull into the garage, I just had this overwhelming thought, god, I hope it's a girl. And, you know, I didn't I hadn't said anything. And right as I went to pick the flowers up in our garage, they basically kind of fell open, and I saw it was pink. And I was just overcome with joy, and I had to pretend that I didn't know. But I walked in and I opened it up, and my my wife was, absolutely overjoyed as well. And at the time, my my first company was an apparel company, so my my colleague had also put a pink shirt in there, one of our pink shirts as a company. So that was a fun way to tie that together. Kevin Lavelle [00:03:54]: And shortly after she learned it was a girl, she said, I really wanted it to be a girl. And I was like, I did too. And by the way, I found out in the garage. And so, a very fond memory, not just learning that it was going to be a girl and and, you know, knowing that we now had a son and a daughter, but, a very memorable time in our lives. And it was a very rough pregnancy for my wife. And I don't know how true this is or an old wives tale that, you know, when it's a girl, they they suck all the pretty and all the life out of you because they're they're bringing it into themselves. And we were joking because it was a much rougher pregnancy with my daughter than my son. So we we we kind of felt it might have been a girl. Dr. Christopher Lewis [00:04:30]: Now I talk to a lot of dads, and a lot of the fathers talk about the fact that they are that there is fear going into being a father to a daughter. Whether found or unfound, it's there. So as you think about the years that you've had with your daughter thus far and you think about your own experiences, what's been your biggest fear in raising a daughter? Kevin Lavelle [00:04:53]: The most direct fear as she gets older, women are more vulnerable in society and all of history than men. That's just the nature of humanity and the nature of life. And so, higher fear that she could have something terrible happen to her than to my son. Although, as parents in an ever crazier and changing world, certainly, the fear exists, for both of them. But my focus, and my wife and I have the same belief, is help our kids there's a phrase, prepare the child for the road and not the road for the child. And I see it so often, especially in some of the schools that we have been in. Whether it's parents or teachers or both, they want to make sure that everything is perfect for their child rather than, how do I make my child resilient and capable of addressing whatever it is that life will bring to them. And so, everything that we can do to make them more resilient and just prepared and understand the risks that exist in the world while not being afraid of the world. Kevin Lavelle [00:05:52]: You could hide out real easily and miss out on a lot of the wonderful things that life has to offer. And and we want them to face the world with head held high and and know what they're capable of. Dr. Christopher Lewis [00:06:02]: Now you're a busy guy. You're a CEO, entrepreneur. You have been involved with a couple of ventures and a couple of companies in your time as a father. And it not only takes time, effort, but it takes balance. So talk to me about what you've had to do to be able to balance all that you're doing in starting and creating a new company, but also in trying to be that engaged father that you wanna be. Kevin Lavelle [00:06:30]: There are lots of people much more smarter and accomplished than me than that probably have lots of specific tips and tricks. But I'll say the thing that has resonated or or stuck with me the most is accepting that I will never get it all done. And I could work round the clock and miss out on life in front of me. We lost my wife's mother now about a decade ago. And that was very young to lose her. And just understanding that life is very short and very precious. And so don't miss out on don't miss out on what's in front of you. And the age old adage, the nights are long, especially when it comes to sleeplessness in those early years, but the years are short. Kevin Lavelle [00:07:10]: And I had quite a few people say that to me when my kids were, you know, 6, 9 months old. And you're not sleeping. And it is a level of exhaustion. Even if your kids are doing well sleeping through the night, it's just so all consuming and difficult and everything is new and stressful. Sometimes, when people tell that to you in that time of life, you're like, thanks. That's super helpful. I'm barely making it in a given day. But just continuing to come back to how fortunate we are. Kevin Lavelle [00:07:35]: We have 2 healthy kids. That is in and of itself a miracle. And then, prioritizing as much as I can. I've been volunteer soccer coach for my son, taking my daughter to her gymnastics classes, and just trying to soak up the time with them because it's moving very quickly. And there's never going to be enough hours in the day to do all the things that I want to do. But making sure that when I'm with them, try to be as as present as possible. I could talk about this for hours, but those would be the biggest things that that really stand out to me. And then, I think I'd also just add, with that said, I heard a Naval Ravikant years ago podcast with somebody was saying that he does a good job of, I think in his own words, he said being appropriately selfish. Kevin Lavelle [00:08:18]: And it comes down to this analogy of put your own oxygen mask on first. If you're not sleeping and eating and taking care of your body and your mind, then you can't take care of your family. You can't be there for them. You can't be a leader. And so, I think some people end up losing sight of that and forget that they still need to have some fun. They still need to take care of themselves. They need to get sleep. Then they need to be able to sit down and read a book or chat with friends. Kevin Lavelle [00:08:44]: And and you it is very easy to lose sight of that, especially in the days of of of young kids. And ultimately, looking at some of my friends whose kids are a bit older, and they're starting to adjust to the fact that they don't spend much time with their kids anymore even though they still live at home. And so that window of time is is very short. Dr. Christopher Lewis [00:09:02]: It is very short. And as your kids get older, you look back and say, dang it. Because, hopefully, you have taken the time to be able to build those really strong relationships, spent the time, and not focus on work or not focus on the things that you think are important at the time to be able to provide for your family, but what you come to find. And I see that even though I've been a very engaged father throughout my entire kids' lives. But as you get into the teenage years and they start pulling away, and you're not able to have as many opportunities to be able to connect and engage on a regular basis, you treasure the moments that you do have to be able to create those opportunities and have those opportunities. And they look and feel a little bit different, But you definitely want to grab them, hold them, and keep doing those things with them when they give you that opening to do it. Now I asked you about if there were any things that you were afraid of and fear in that regard. But being a parent is not always easy. Dr. Christopher Lewis [00:10:07]: We just talked about and we'll talk more about the fact of sleep and the importance of sleep. But it's not always easy to be a father to a son, a father to a daughter. What would you say has been the hardest part for you in being a father to a daughter? Kevin Lavelle [00:10:21]: If I had to sum it up, I think overall, I would pick up 2 different angles to this. And I can hone in on it being daughter specific and also being a father specific. It's not specifically daughter related, but it is very much a central struggle to being a parent. And it's something that I see, I don't say this on a high horse, but it's something I see a lot of other parents neglect. And I can see it coming back to bite them, which is raising good, capable kids who are respectful and that you want to spend time with is there's a pretty significant amount of time that is frustrating and you have to be, you have to be the parent. You have to be the adult. You have to be the rule enforcer. You have to constantly give feedback and it's frustrating and it's challenging. Kevin Lavelle [00:11:03]: But when you don't do that, each passing day, week, month, and year, it's harder to raise good, respectful kids that are capable and, you know, you want to spend time with. Jordan Peterson, I think it was in his 12 Rules For Life, talked about you don't let your kids do things that make you like them less because you love them more than anyone else in the world. And if you let their bad behavior go, their obnoxious behavior, even annoying tendencies, if you don't help them correct those, well, guess what the rest of the world's gonna do? They're not really gonna like them either. They're not gonna want to engage with them. They're not gonna want to be friends with them. They're not gonna wanna help them, mentor them, etcetera. And so I think about this a lot, especially when I have those frustrating conversations or interactions that I have to work very hard to help them grow and flourish. And that means I'm bearing a lot of the brunt of that so that they, in the rest of the world, have people like them and want to be around them. Kevin Lavelle [00:12:01]: And one of the things that my wife and I are most proud of on an ongoing basis is when people are around our kids, they are genuinely surprised at how wonderful they are to be around. They're very respectful. We can go to very nice restaurants with them without an iPad. And they do great. And that I don't know how many times we went to a restaurant where it wasn't awesome before it started to be good. And now, it's great. And so, you know, I think with that, that is not necessarily daughter specific. I'll go with now daughter specific. Kevin Lavelle [00:12:33]: And the other key piece here is you don't raise your kids in a vacuum. And our kids go to school with other kids whose parents are fine with different approaches to language and respect and electronics and vanity and spending. And there's a when our kids spend time with certain kids, they come home with very annoying or inappropriate kind of phrases or responses. And it's getting a little bit better because they know what, they tend to understand more of what's right and wrong and what is and isn't acceptable. But when they are in school all day or they spend time with certain kids, they come home with things that we have to then work to correct. And it's not a huge problem. But, you know, when you send your kids out into the world, you have to remember they're out in the world without you. And that's why it's so important to build those innate characteristics. Kevin Lavelle [00:13:25]: And especially on the little girl front, some parents have no problem with makeup and music and things that are just not appropriate for my daughter's age. And then she's struggling with this back and forth of, well, I see my friends do it and their parents are okay with it. And you have to say, while being respectful, you can't really say, well, those are not good parents in our view. Because there's a way to say that that inspires better decision making. And there's a way to say that that could make them look down upon or feel differently about folks. That's that's not not helpful. People can parent hard, but they want to parent. My job is to take care of my kids. Dr. Christopher Lewis [00:14:03]: Well, and the other thing that I think that all of us have to understand is that each of us come into parenting without a rule book, without a guide book. And depending on the model that you saw in your own experience as a child yourself, the other parents that you surround yourself with, you start to identify and create ways in which you parent based on those. And sometimes parents don't realize what they're doing or are not doing, and unless someone points it out to them as well. But I completely understand what you're saying because sometimes you do have to do that deprogramming with your kids when they get back into your home or if they've spent time even when they go to grandparents and they come home, and the rules are different there. And then they come back and are like, well, grandma and grandpa said it was okay, so why not here? And you have to deal with that as well. So I completely understand what you're saying in that regard. Now we've been talking and kinda hinting about the importance of sleep. And as I mentioned at the beginning, you are the CEO and cofounder of Harbor. Dr. Christopher Lewis [00:15:11]: It is a organization company that is working to create happier parents and healthier families, as I said, one restful night at a time. And I remember those days with both my kids feeling like a zombie when you're trying to go to work, and you're coming home, and, you know, you're getting a few hours of sleep. And, you know, those things are very challenging, and those those days and nights can be long. And that being said, I wanted to ask you about Harbor because, like you said, you spent quite a few years at Mizzen and Main, which is a clothing company. And you pivoted after this to open your own organization and create your own company in that regard and beyond what you did at Mizzen and Main to something completely different. So talk to me about that origin story of Arbor. And what made you decide to move away from clothing and move toward something that we're talking about in regards to helping parents to get better sleep, to be able to stay connected with their children, and be able to create this new product? Kevin Lavelle [00:16:17]: So when my son was born, it was a very memorable time in my life. Also, similar to that very visceral memory of finding out my second was gonna be a girl. We were in the throes of fundraising for Mizzen and Maine. We were assigned the term sheet with our private equity firm in the delivery room for my son. And I remember pieces of that very vividly. And one of them was, I'm not the person who's going to decide the car seat or the stroller. I was helpful with my wife there where she wanted me to. But I'm more of the tech person, and I did a lot of research. Kevin Lavelle [00:16:49]: And there was a company called Nanit that had a lot of recognition and press about their very innovative baby monitor. It's a Wi Fi camera with an app on your phone. And I thought, oh, that's really neat. I like apps on my phone. That's convenient. But while someone was a couple, I don't know, weeks or months old, I can't remember the exact date that it happened. And he was in his own room. And I woke up one morning and the app on my phone, because you have to sleep next to your phone, which I don't like doing to begin with, but you have to sleep next to your phone so the app audio runs in the background. Kevin Lavelle [00:17:18]: The app had just crashed. And look, apps crash. They're not a 100% reliable. And I panicked and ran across the house. And, of course, he was fine. Kids are more resilient than we give them credit for. But it was a very alarming realization that this thing that I'm supposed to be able to rely on, you I can't. And so we went out that day and bought an old school Motorola camera and an old school Motorola monitor that was direct local only communication. Kevin Lavelle [00:17:46]: It does not use the Internet in any way, shape, or form. But we kept a Wi Fi camera. I got rid of the Nanit and ended up just using a Google Home device, a Nest camera, because my wife and I worked together at Mizzen and Maine. And when she came back to work, we wanted to be able to check-in on the nanny with a babysitter. You just you wanna be able to know. And not that I wanna be monitoring 20 fourseven, but technology is supposed to make our lives better. And there have been a lot of promises that have largely failed to deliver for parents. So this idea of why do I have 2 separate systems to be able to just know that I'm monitoring my kid and record and rewind and check out from outside the house? I talked to a lot of parents over the last 8 years and just sort of getting feedback and wondering what they were using. Kevin Lavelle [00:18:32]: And I found out that 20 to 30 plus percent of my friends did the same thing that I did, was have multiple systems. And in an industry and in a time of life when parents want the best for their kids, baby registries are between $3 and probably $15,000 worth of products as a first time parent. Cribs and strollers and car seats and multiple strollers and formula and and pumps and on and on and on and on. The best that parents have to offer or the best that parents have accessible to them is hacking together multiple systems that don't communicate with each other and blah blah blah. So I wanted to solve this problem since my son was born. And so what we've built is a camera and a 10 inch monitor that connect directly to each other without Internet. And both devices also connect to the Internet. So you get the best of both worlds. Kevin Lavelle [00:19:29]: It's a dedicated device that alerts you if you lose connection. And everything connects to the Internet when it's available. So we have an app. You can record. You can rewind. You get all of those benefits and features as well. I've got one right over here. I should have had it right next to me. Kevin Lavelle [00:19:44]: But it is a 10 inch monitor. So you can actually watch up to 4 different streams on one screen. You can control the zoom and the volume of each independently. There's nothing like that that exists today. And I can tell you, however bad the experience was with a Wi Fi camera with 1 child with 2, it's it's almost impossible on a tiny little iPhone screen. And we can watch up to 4. And then we put privacy first. So our camera and our tablet are both built outside of China. Kevin Lavelle [00:20:10]: They're both built with non Chinese silicon. The chips inside the device is basically the thing that powers it from a processor perspective. And then the chip in the camera is able to do all of the advanced analytics and kind of signal to noise sorting that makes our product really unique on the device locally. Meaning, it does not go through our cloud to process your information. And the the best way to think about that is like on a self driving car on a Tesla, they have cameras that process everything locally. Because if you had to send to the Internet, is that a red light or a green light? Obviously, that's not very safe from a decision making time frame. And then we also put a memory chip in the camera. So all of your memories are stored locally on the device itself. Kevin Lavelle [00:20:52]: If you wanna use our app, obviously, if you're outside the house, you will access it, and that will be remote. We're not storing it. We're not processing it. Unlike every other Wi Fi camera that exists, you are paying them to store your footage on their cloud. And in many cases, third party clouds that may not have the same level of security that you would expect. So very unique device, very unique monitor. We've really positioned ourselves as something that does not exist today for parents and started shipping mass production units to customers in September of 2024. And it's going great so far. Kevin Lavelle [00:21:24]: We've shipped thousands of devices in just a few months. And then the other thing I'll touch on very briefly for framing is that's exciting and and we think a game changer for parents. And it's been very well received. But we are using it as the foundation for what we have called a remote night nanny. So if you can afford it, an in home night nanny or night nurse is one of life's greatest blessings. It's also unaffordable for almost everybody. And a lot of people who can afford it don't want someone else in their house, or they heard a horror story and they don't feel comfortable with it. Or even if they can afford it, they can't really find someone that they would trust to come in and help take care of their child. Kevin Lavelle [00:21:57]: And the main purpose of an in home night nanny is they will listen to your baby monitor in another room, and they will go in when it is necessary and appropriate to go in. So if your child starts to fuss or cry a little bit, they'll look at the monitor. Okay. Nothing's wrong. And they basically start a timer and they wait 5, 10, 15 minutes depending on age and stage. Because if you hear a child cry and immediately run-in, you delay their ability to learn how to sleep because sleep is a skill. Just like talking and walking, you have to kind of fumble through it and you and you find your way and you develop the skill of sleeping. There's a lot of really bad information out there on the Internet about sleep. Kevin Lavelle [00:22:36]: And sleep experts, legitimate ones, know you have to help the child learn how to sleep. And so, the challenges in home night nannies, if you can find 1, are $300 to $700 a night depending on where you live in the country. And it's very hard to find them as well. So, what we're doing is because we have built the hardware, after you onboard into our system, you can hire our professionally trained night nurses remotely. You press a button on the monitor, sort of like arming an alarm system, and that turns over the controls of your monitor to our professionally trained night nurses. We turn the volume on your monitor down to 0 all night long and only wake you up when a professionally trained night nurse says it's time to go in. So if something is wrong, like something falls in the crib or the baby's arm gets out of the swaddle and gets stuck in the crib slot, we're gonna wake you up immediately. Otherwise, we're gonna start the timer and we're going to wait until it is time for you to go in. Kevin Lavelle [00:23:33]: And what we have found is the 1st night, parents are adjusting to, okay, this is a little different and a little a little new. But the 2nd night, parents are telling us they've things like, I haven't slept this well since my 1st trimester. And that's because it's not just that I'm not hearing something. Because you may not go in all night long, but your child is going to make noises all night long. Kids make a lot of noise. And if you don't remember it, good for you. That's fortunate. But kids can fuss and cry off and on for hours. Kevin Lavelle [00:24:03]: Now, they're still getting sleep in between, but you're not as a parent. But what we're finding is parents are telling us, especially moms, to have a professional be the one that is helping me know when to go in rather than that anxiety and that guilt and that shame that comes with being a parent and not knowing what to do, It allowed me to really actually get deep, restful sleep for the first time in a long time. And because we have built the hardware, we have a lot of fail safes built in, the system just turns itself back on if it loses connection, And we're hiring professionally trained nurses so that we can have 1 nurse work with multiple families at the same time and bring the cost down to about 5% of the cost of an in home night nanny. So that's Harbor. A lot more to talk about there, but that's a good good roundup of what we've built here. No. Dr. Christopher Lewis [00:24:51]: It sounds like an amazing product, and I have not used it, and I don't need it now. And my kids would be really weirded out if I was using it at this point in their lives. But that being said, when they were very young, this sounds like a game changer. Now one question that I had when you were talking about the technology and, you know, how you had your app and that you were trying to keep it on a phone and and that it was running and then lose power and you you know, all of that story that you told. With your system, are you running off of your Wi Fi in your home, or are you running off of the Wi Fi off your phones? Because if the power goes out, then, you know, how does that all work? Kevin Lavelle [00:25:31]: Yeah. So a couple of points on the technical side. The camera and the monitor or multiple cameras are going to run off your home Wi Fi when it is strong and available. If you don't have Wi Fi, so as a point of comparison, if you have one of these Wi Fi baby monitor systems and you travel to a hotel, you can't use it because hotels will not let you tap your devices onto their Wi Fi. You can put your phone on it, but you can't run your devices on their networks from a security perspective. So the message boards online are full of parents who said, you know, just got to our hotel and realized I can't use my Nanette. I can't use my Owlette. And I had to run to Walmart to get a baby monitor because, you know, get adjoining rooms. Kevin Lavelle [00:26:11]: You gotta be able to look in. And so the camera and the monitor, one camera and one monitor, creates its own Wi Fi signal to communicate directly with each other while not requiring a separate Wi Fi network. So it has direct local communication that doesn't require the Internet. But when you're at home and your your routers are appropriately configured and and everything is running, it will just run through your home home Wi Fi. And one of the benefits there is home Wi Fi tends to be stronger. You've got it across the entire house. And our that feed does not leave your home. So if it's running on your home WiFi, it does not leave your home. Kevin Lavelle [00:26:50]: Again, we are not swearing or processing anything. If your router goes down, if your Internet goes down, then your camera will fail over to direct local communication. So when it's running through your home WiFi, it's saying, okay. I'm running through home WiFi. I've got good signal strength. All of that's measured. When it can't find that home WiFi or it's not working, then it says connect directly to the monitor. Now with a power outage, at that point in time, if you were running an app on your phone, the camera is going to fail because no baby monitor cameras come with batteries. Kevin Lavelle [00:27:23]: I'll say none. Virtually none do because batteries are a severe fire risk, especially if it's running 247. And that's why, generally, you will not see batteries in cameras in homes. And so if there's a power outage, you wouldn't necessarily be notified if you're just using a WiFi camera. But our monitor would know, hey, I've lost connection with that camera because the cameras no longer has power. I'm going to alert the parents that there's no longer a connection. Now, that doesn't mean you can do anything about it because you don't have power in your house. But now you know, and you can choose to maybe open the doors so that you can still hear, maybe bring the crib into your room. Kevin Lavelle [00:28:02]: That's then a parental decision on what happens next. But the important thing is we empower parents to know what's actually happening. Dr. Christopher Lewis [00:28:09]: And about the night nurses, tell me about how do you identify these individuals? What type of background do they have? How are they trained to be able to provide that kind of service for families? Kevin Lavelle [00:28:18]: So we're recruiting actual nurses who have worked in pediatrics, whether in offices or hospitals. And then in some cases, they have in home night nursing experience where they have worked with families and homes. And in other cases, they just have pediatrics medical experience. And then we are training them from our professionally trained night nursing staff. So, our director of nursing has worked for years in hospitals. She was a pediatric oncology nurse. She worked as an in home care manager and as an in home night nurse. She's a Hmong herself. Kevin Lavelle [00:28:49]: And so she is working with one of our advisors and our team on training those nurses that we're bringing in. Dr. Christopher Lewis [00:28:56]: And as you said, those in home nannies or nurses that you might have inside your home can be very expensive. What's the price point on not only your system, but having this type of monitoring with night nurses to be able to assist parents? Kevin Lavelle [00:29:09]: To buy our camera and our monitor and all of our features, we do not require subscriptions or additional payments. You buy a camera and a monitor, you get everything forever. It's $599, which puts us as roughly price comparable to all the other leading systems on the market today because they require annual subscriptions. And then the remote night nanny experience, right now, is about $30 a night. You have to buy kind of packages of nights, and it works out to about $30 a night. And our long term vision is to get the cost down to $20 a night. Once we have enough people in the system and we can hire the staff and have the systems capable of working with many more families at the same time, we will continue to pass those cost savings on to our customers. And it's kind of cool. Kevin Lavelle [00:29:51]: At $20 a night, you could do 3 months of the remote night nanny for the same cost of about 1 week of an in home night nanny. And so we like to say 95% of the benefit and 5% of the cost of an in home night nanny. Dr. Christopher Lewis [00:30:06]: Well, it's a great value for families and definitely gives families peace of mind in regard to being able to be if you are sleeping and you get that good sleep, you're going to be able to be more present and be able to be much more attuned to what your child needs versus trying to struggle through with the lack of sleep that many parents get, especially for the 1st 6 months, 8 months, year, or more, depending on your child, that sometimes you run into. Kevin Lavelle [00:30:37]: Yeah. I mean, there's a lot of different studies and research, but very significant percentage of couples who get divorced say sleeplessness in the early years of childhood was a major contributing factor. The reality is a lack of sleep contributes to or exacerbates postpartum depression. It has very significant immune system impacts, durability, even to be a safe driver. When you are sleep deprived, whether you have a child or not, sleep deprived drivers can be even more dangerous than drunk drivers. And so, there's a lot from the adult side. And then on the child side, we make a big difference for parents. But on the other side, our monitor system is the kind of help parents and kids get more sleep. Kevin Lavelle [00:31:14]: That's the fundamental nature of our system relative to everything else. The single best thing that you can do for your child is obviously make sure they have appropriate nutrition in those early years, in early months weeks years. The second best thing that you can do for them is make sure that they are getting the appropriate amount of sleep on a consistent basis. And that is really hard to do for most parents for a whole host of very obvious reasons. And so, when you think about a well rested child, certainly, we can imagine they are more pleasant to be around. But from a mental development perspective, from a dysregulation perspective, from an immune system perspective, from a physical health development perspective, all of those, you have to have the right nutrition and you have to have the right sleep. And if you are not supporting your child's ability to sleep through the night, you are very much hampering their health and well-being and development. And I'll say one final note on sleep. Kevin Lavelle [00:32:11]: There are some very bad influencers and sleep gurus that will tell you the minute your child is crying, you need to be in there holding their hands and they will feel abandoned. Science has disproven this again and again and again. And similar to this idea of put your own oxygen mask on first, when moms don't get sleep, the propensity for postpartum depression absolutely skyrockets for all the obvious reasons. And when a mom has postpartum depression, it has a very significant impact on her ability to feed her child, nurture her child, love her child. It's a very difficult thing to go through. Obviously, there's no way that I could go through it, but it is a very understandable position that moms find themselves in. And so, these influencers and sleep gurus who, you know, propagate very bad sleep ideas, they're really harming parents' ability to get the right information and support their their families. And so, our focus is how do we help parents who want help? I'm never going to tell a parent, you're doing it wrong. Kevin Lavelle [00:33:15]: Every parent is responsible for raising their own child and we all have our own way. However, most parents are struggling and need some help. And we are here to provide very clear, unambiguous, science backed information. And we do that for free. At our website, harbor.co, we have a ton of free resources. And our mission is happier parents and healthier families. And so, we have a lot of free resources on our website. If you don't want to buy our baby monitor for any number of reasons, that's fine. Kevin Lavelle [00:33:41]: There's still a lot of great resources that you can find. And we have opportunities for parents to sign up for text based sleep coaching. If they just want to text a nurse and get some help, it's a very affordable $30 a month. You don't have to sign up for big hour long sessions or sign up for our full system, although we offer those as well. Dr. Christopher Lewis [00:33:58]: Well, Kevin, I wanna say thank you for sharing all of that. If people wanna find out more about your system, the night nanny services, or anything else, where should they go? Kevin Lavelle [00:34:10]: Harbor.co. And you can find us on on the socials at harbor sleep. And we have so many great resources there. We have very robust sleep guides for infants and also toddlers. We have also formed a harbor council of pediatric sleep doctors, postpartum counselors, pediatricians, OB GYNs that have written many articles for us. And our goal is if you have a question as a parent, we don't have all the answers yet, but we have pushed a lot of great content for free online to be a great resource for parents as they need it. Dr. Christopher Lewis [00:34:45]: Now we always finish our interviews with what I like to call our fatherhood 5, where I ask you 5 more questions to delve deeper into you as a dad. Are you ready? Yes. In one word, what is fatherhood? Kevin Lavelle [00:34:55]: Joy. Dr. Christopher Lewis [00:34:55]: When was the time that you finally felt like you succeeded at being a father to a daughter? Kevin Lavelle [00:35:01]: I don't think I could point to, like, we were at a theme park or we were at a restaurant. To me, it's those moments where my daughter would look at me, come home from work, come home from traveling, I'm tucking her in at night. And I just see that look in her eye that says, you are my safety, you are my home. The level of connection and love there, that success is a dad. Dr. Christopher Lewis [00:35:24]: Now if I was to talk to your kids, how would they describe you as a dad? Kevin Lavelle [00:35:28]: I believe they would say fun, strong, great. And those are the things that that I hope that they would say at their ages with their vocabulary. Some of the kind of underlying things would be that I'm supportive, that we have a lot of fun together. We laugh, chase them around the house, and that they still really want to spend time with me. They've got friends, but generally, they'd rather spend time with my wife and I than anyone else. Dr. Christopher Lewis [00:35:54]: Now let's go 10 years down the road. What do you want them to say then? Kevin Lavelle [00:35:57]: As I think about this phase of life, we no longer have little kids. They're not toddlers, and they go to school full time. And my wife and I have talked about, like, we did it. We got out of the the infant and toddler and very young kid phase as best as we possibly could have. We have wonderful kids. They're respectful. They're resilient. They like to learn. Kevin Lavelle [00:36:22]: They like to have fun. They're great kids. Now, we need to prepare them to be teenagers. And so, what would I hope to feel like at that point in time? That whatever it is that our kids want to do, whether they want to go to college, whether they want to pursue a sport, whatever it is. That they are ready to go face the world and they are as prepared as they possibly could be. As I said, prepare the child for the road. And that they truly understand, as best as a, you know, 18 year old can, what it means to be happy. That they will not chase the superficial. Kevin Lavelle [00:36:54]: That they will chase the core, the meaningful, the spiritual in whatever way that is for them. Dr. Christopher Lewis [00:37:00]: Now, who inspires you to be a better dad? Kevin Lavelle [00:37:03]: Certainly, I feel like I won the parent lottery. My parents raised me right. And I felt my whole life the appropriate balance of support and safety, but also go forth and conquer. My wife, she is an absolutely incredible mother, and I think a better mother than I am father. And, you know, as cliche as it is, my kids. When they show me that they want to spend time with me and that they want more of me and that they're truly grateful for the life that we have as best as young kids can, that, okay, keep going. I want to do more of it. Dr. Christopher Lewis [00:37:34]: Now, you've given a lot of piece of advice today, things that people can think about and look at ways in which they can incorporate some of those pieces into their own experience as a father. If you are talking to a father, what's one piece of advice you'd want to give to every father out there? Kevin Lavelle [00:37:50]: So for the dads that have kids older than me, I'm not sure how much advice I could give. But for those coming up behind me with with younger kids, I think it's a big part of what we talked about. Raise kids that you want to be around and that they love you. Like, that they are the kids that other people want to spend time with and that they want to spend time with you. That that kind of full circle. And if you do those two things, then you're doing all the other things right. And that's a good kind of metric or or baseline to seek. And as cliche as it is, it goes by really fast. Dr. Christopher Lewis [00:38:27]: It definitely does. Well, Kevin, I just wanna say thank you. Thank you for sharing your journey today. And as Kevin said, if you wanna find out more about him or about his company, go to harbor.co to find out more information about this amazing new technology and resource for you as you are working to be the best dad that you wanna be. Kevin, thanks so much for being here today. Kevin Lavelle [00:38:51]: Thanks for the opportunity and and for the inspiring work you do for dads. Dr. Christopher Lewis [00:38:55]: If you've enjoyed today's episode of the Dads with Daughters podcast, we invite you to check out the fatherhood insider. The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step roadmaps, and more, you will engage and learn with experts, but more importantly, dads like you. So check it out at fathering together dot org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with daughters is a program of fathering together. We look forward to having you back for another great guest next week all geared to helping you raise strong and powered daughters and be the best dad that you can be. Dr. Christopher Lewis [00:39:54]: We're all in the same boat, and it's full of tiny screaming passengers. We spend the time, we give the lessons, we make the meals, We buy them presents and bring your AK. Because those kids are growing fast. The time goes by just like a dynamite blast. Be the best dad you can be. You're the best dad you can be.

JCO PO author Dr. David R. Gandara at UC Davis Comprehensive Cancer Center, shares insights into his JCO PO article, “Plasma Proteome–Based Test for First-Line Treatment Selection in Metastatic Non–Small Cell Lung Cancer,” one of the Top Articles of 2024. Host Dr. Rafeh Naqash and Dr. Gandara discuss how the PROphet® blood test supports first-line immunotherapy treatment decisions for metastatic NSCLC patients. 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 JCOPO 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 absolutely thrilled to be joined by Dr. David R. Gandara, Professor of Medicine Emeritus, Co-Director of the Center for Experimental Therapeutics and Cancer and Senior Advisor to the Director at UC Davis Comprehensive Cancer Center and also the senior author of the JCO Precision Oncology article entitled “Plasma Proteome–Based Test for First-Line Treatment Selection in Metastatic Non–Small Cell Lung Cancer.” This was one of the top performing articles of 2024, which is one of the reasons why we wanted to bring it in for a podcast discussion. At the time of this recording, our guest's disclosures will be linked in the transcript.  David, it is an absolute pleasure to have you today. For somebody like you who's led the field of lung cancer over the years, I'm really excited that you are going to be talking to us about this very interesting article, especially given that I think you're one of the big proponents of liquid biopsies and plasma-based testing. So, for the sake of our listeners - which comprises of academic oncologists, community oncologists, trainees - could you tell us where the biomarker landscape for non-small cell lung cancer is currently, and then we can try to take a deeper dive into this article. Dr. David Gandar: Okay. Well, thank you, Rafeh. It's a pleasure to be with you here today. And I think the current landscape for biomarkers for immunotherapy in non-small cell lung cancer is a mess. There's no better way to describe it. That makes this paper describing a new plasma proteomic assay even more important. So I'll just give you a perspective. There are 14 trials, phase three trials, that were done in first line non-small cell lung cancer advanced stage of immunotherapy versus chemotherapy and some other aspects, although they vary tremendously. Some of them were checkpoint monotherapy, some combined with chemotherapy, some combined with CTLA-4 inhibitors and so forth. 12 out of the 14 were positive, 12 got FDA approval. So there are 12 different options that an oncologist could use. Some of them were squamous cell only, some non-squamous, some used PD-L1 as a biomarker driven part of the study. Some used TMB, tumor mutational burden, some were agnostic. So when you put all of this together, an oncologist can pick and choose among all these various regimens. And by and large, it's PD-L1 that is the therapeutic decision maker.  ASCO actually, I think, has done the very best job of making a guideline, and it's, as you well know, called a living guideline, it's dynamic. And it is much easier to interpret, for me and I think for oncologists, than some of the other guidelines. It's got a green light and a red light, it may be kind of orange. And so the green light means this is a strong recommendation by the guideline committee. The orange means it's weak. For this purpose, non-small cell lung cancer, advanced stage, only a very few of the recommendations were green. It's mainly monotherapy and patients with cancers with a PD-L1 over 50%. In our surveys, at our meetings, less than 50% of oncologists in the United States are following these guidelines. Why? Because they don't trust the biomarker. And TMB has the same sort of limitations. They're not bad biomarkers, they're incomplete. They're only looking at a part of the story. So that means we need a new biomarker. And this is one that, I think, the data are quite impressive and we'll discuss it more. Dr. Rafeh Naqash: Absolutely. Like you said, abundance of many therapy options, but not necessarily everything works the same in different subsets of PD-L1 positivity or different subsets of patients with different levels of tumor burden. And like you said, again, difficulty in trying to identify the right biomarker. And that's a nice segue to this PROphet test that you guys ran. So can you tell us a little bit about the plasma proteomic assay? Because to the best of my knowledge, there's not a lot of validated plasma proteomic assays. A lot has been done on the tumor tissue side as far as biomarkers are concerned, but not much on the blood side, except for maybe ctDNA MRD testing. So what was the background for trying to develop a plasma-based proteomic test? And then how did this idea of testing it in the lung cancer setting come into play? And then we can go into the patient population specifics, the cohort that you guys have. Dr. David Gandara: Okay. Well, of course there's a company behind this assay, it's called OncoHost, and I'm a consultant for them. And they came to me two years ago and they said, “We have something different from anyone else.” And they explained the science to me, as well as some other lung cancer experts here in the United States. I'm not a proteomic expert, of course, but they developed an AI machine learning platform to assess plasma proteins in normal people and in people with cancer, and specifically then in people with non-small cell lung cancer. They identified over 7,000 proteins that had cancer implications for therapy, for resistance, for prognosis, etc., and they categorized them based on the literature, TCGA data, etc., and used this machine learning process to figure out which proteins might be most specific for non-small cell lung cancer. And that's where they started. And so out of that 7,000 proteins, where they've identified which ones are angiogenic, which ones are involved with EMT or cell cycle or whatever it might be, they distilled it down to 388 proteins which they thought were worth testing in non-small cell lung cancer. And that's when I became involved.  They had a retrospective cohort of patients that had been treated with various immunotherapies. They looked at the analytic validation first, then applied it to this cohort. It looked good. Then they had a very large cohort, which they split, as you usually do with an assay, into a test set and then a validation set. For the test set, they wanted something more than a response. They wanted some indicator of long term benefit because that's where immunotherapy differentiates itself from chemotherapy and even targeted therapy. And so they picked PFS at 12 months. And I became involved at that point and it looked really good. I mean, if you look at the figures in the manuscript, the AUC is superb about their prediction and then what actually happened in the patient. And then in this paper, we applied it to a validation set of over 500 patients in a prospective trial, not randomized, it's called an observational trial. The investigator got to pick what they thought was the best therapy for that patient. And then in a blinded fashion, the proteomic assay experts did the analysis and applied it to the group.  And so what that means is some of the patients got chemotherapy alone, some got checkpoint immunotherapy monotherapy, some got in combination with chemotherapy. None of the patients in this study got a CTLA-4 inhibitor. That work is ongoing now. But what the study showed was that this assay can be used together with PD-L1 as what I would call a composite biomarker. You take the two together and it informs the oncologist about the meaning of that PD-L1. I'll give you an example. If that patient has a PD-L1 over 50% in their cancer and yet the PROphet test is negative, meaning less than 5 - it's a 0 to 10 scale - that patient for survival is better served by getting chemotherapy and immunotherapy. However, if the PROphet test is positive and the PD-L1 is over 50%, then the survival curves really look equivalent. As I said earlier, even in that group of patients, a lot of oncologists are reluctant to give them monotherapy. So if you have a test and the same sort of example is true for PD-L1 0, that you can differentiate. So this can really help inform the oncologist about what direction to go. And of course then you use your clinical judgment, you look at what you think of as the aggressiveness of the tumor or their liver metastases, etc. So again, that's how this test is being used for non-small cell lung cancer. And maybe I'll stop there and then I'll come back and add some other points. Dr. Rafeh Naqash: I definitely like your analogy of this therapy de-escalation strategy. Like you mentioned for PD-L1 high where the PROphet test is negative, then perhaps you could just go with immunotherapy alone. In fact, interestingly enough, I was invited to a talk at SITC a couple of weeks back and this exact figure that you're referring to was one of the figures in my slide deck. And it happened by chance that I realized that we were doing a podcast on the same paper today.  So I guess from a provocative question standpoint, when you look at the PD-L1 high cohort in the subset where you didn't see a survival difference for chemo plus immunotherapy versus immunotherapy alone, do you think any element of that could have been influenced by the degree of PD-L1 positivity above 50%? Meaning could there have been a cohort that is, let's say PD-L1 75 and above, and that kind of skews the data because I know you've published on this yourself also where the higher the PD-L1 above 50%, like 90% PD-L1 positivity survival curves are much better than 50% to 89%. So could that have somehow played a role? Dr. David Gandara: The first thing to say is that PD-L1 and the PROphet score, there's very little overlap. I know that sounds surprising, but it's also true for tumor mutational burden. There's very little overlap. They're measuring different things. The PD-L1 is measuring a specific regulatory protein that is applicable to some patients, but not all. That's why even in almost all of the studies, people with PD-L1 0 could still have some survival benefit. But in this case they're independent. And not in this paper, but in other work done by this group, the PROphet group, they've shown that the PROphet score does not seem to correlate with super high PD-L1. So it's not like the cemiplimab data where if you have a PD-L1 of greater than 90%, then of course the patient does spectacularly with monotherapy. The other thing that's important here is they had a group of around a little less than 100 patients that got chemotherapy alone. The PROphet score is agnostic to chemotherapy. And so that means that you're not just looking at some prognostic factor. It's actually clinical utility on a predictive basis. Dr. Rafeh Naqash: I think those are very important points. I was on a podcast a couple of days back. I think there's a theme these days we're trying to do for JCO Precision Oncology, we're trying to do a few biomarker based podcasts, and the most recent one that we did was using a tissue transcriptome with ctDNA MRD and you mentioned the composite of the PD-L1 and the PROphet test and they use a composite of the tissue transcriptome. I believe they called it the VIGex test as well as MRD ctDNA. And when your ctDNA was negative at, I believe, the three month mark, those individuals had the highest inflamed VIGex test or highest infiltration of T cells, STING pathway, etc. So are there any thoughts of trying to add or correlate tissue based biomarkers or ctDNA based correlations as a further validation in this research with the company? Dr. David Gandara: Right. So there are many things that are being looked at, various composites looking at the commutations that might affect the efficacy of immunotherapy and how they correlate with profit positivity or negativity. And I'll just give the examples of STK11 and KEAP1. As you know, there's some controversy about whether these are for immunotherapy, whether they're more prognostic or predictive. I'm one of the co-authors among many in the recently published Nature paper by Dr. Skoulidis and the group at MD Anderson which report that for KEAP1 positive especially, but also SDK11 mutated getting immunotherapy, that that's where the CTLA-4 inhibitors actually play the greatest role. So realizing that this is still controversial, there are preliminary data, not published yet, that'll be presented at an upcoming meeting, looking at many of these other aspects, P53, SCK11, KEAP1, other aspects, TMB, that's actually already published, I think in one of their papers. So yes, there's lots of opportunities.  The other cool thing is that this isn't a test, it's a platform. And so that means that the OncoHost scientists have already said, “What if we look at this test, the assay in a group of patients with small cell lung cancer?” And so I just presented this as a poster at the world conference in San Diego. And it turns out if you look at the biology of small cell, where neither PD-L1 nor TMB seem to be very important, if you look at the biology of small cell and you form an assay, it only shares 44 proteins out of the 388 with non-small cell. It's a different biology. And when we applied that to a group of patients with small cell lung cancer, again it had really pretty impressive results, although still a fairly small number of patients. So we have a big phase three study that we're doing with a pharmaceutical company developing immunotherapy where we are prospectively placing the PROphet test in a small cell trial.  The platform can also be altered for other cancer types. And at AACR, Dr. Jarushka Naidoo presented really impressive data that you can modify the proteins and you can predict immunotherapy side effects. So this is not like a company that says, “We have one test that's great for everything.” You know how some companies say, “Our test, you can use it for everything.” This company is saying we can alter the protein structures using AI machine learning assisted process to do it and we can have a very informed assay in different tumor types and different situations. So to me, it's really exciting. Dr. Rafeh Naqash: Definitely to me, I think, combining the AI machine learning aspect with the possibility of finding or trying to find a composite biomarker using less invasive approaches such as plasma or blood, definitely checks a lot of boxes. And as you mentioned, trying to get it to prospective trials as an integral biomarker perhaps would be likely the next step. And hopefully we see some interesting, exciting results where we can try to match or stratify patients into optimal combination therapies based on this test.  So now to the next aspect of this discussion, David, which I'm really excited about. You've been a leader and a mentor to many. You've led ISLC and several other corporate group organizations, et cetera. Can you tell us, for the sake of all the listeners, junior investigators, trainees, what being a mentor has meant for you? How your career has started many years back and how it's evolved? And what are some of the things that you want to tell people for a successful and a more exciting career as you've led over the years? Dr. David Gandara: Well, thank you for the question. Mentoring is a very important part of my own career. I didn't have an institutional mentor when I was a junior investigator, but I had a lot of senior collaborators, very famous people that kind of took me under their wing and guided me. And I thought when I basically establish myself, I want to give back by being a mentor to other people. And you wouldn't believe the number of people that I'm even mentoring today. And some of them are not medical oncologists, they're surgeons, they're radiation oncologists, they're basic scientists. Because you don't have to be an expert in that person's field to be a mentor. It helps, but in other words, you can guide somebody in what are the decision making processes in your career. When is it time to move from this institution onward because you can't grow in the institution you're in, either because it's too big or it's too small? So I established a leadership academy in the Southwest Oncology Group, SWOG. I've led many mentoring courses, for instance, for ISLC, now for International Society Liquid Biopsy, where I'm the executive committee liaison for what's called The Young Committee. So ISLB Society, totally devoted to liquid biopsy, six years old now, we have a Young Committee that has a budget. They develop projects, they publish articles on their own, they do podcasts. So what I'm saying is those are all things that I think opens up opportunities. They're not waiting behind senior people, they are leading themselves.  We just, at our International Lung Cancer Congress, reestablished a fellows program where a group of fellows are invited to that Huntington beach meeting. It's now in its 25th year and we spend a day and a half with them, mentoring them on career building. I'll just give you my first, I have the “Letterman Top 10”. So my first recommendation is if all you have is lemons, make lemonade. And what I'm meaning is find what you can do at your institution if you're a junior person, what you can claim to be your own and make the very best of it. But then as you get further along in my recommendations, one of them is learn when to say ‘no'. Because as a junior investigator the biggest threat to your career is saying ‘yes' to everybody and then you become overwhelmed and you can't concentrate. So I'll stop there. But anyway, yes, mentoring is a big part of my life. Dr. Rafeh Naqash: Well, thank you, David. This is definitely something that I'm going to try to apply to my career as well. And this has been an absolute pleasure, especially with all the insights that you provided, not just on the scientific side but also on the personal career side and the mentorship side. And hopefully we'll see more of this work that you and other investigators have led and collaborated on. perhaps more interesting plasma based biomarkers. And hopefully some of that work will find its home in JCO Precision Oncology. Thank you again for joining us today. Dr. David Gandara: My pleasure. Dr. Rafeh Naqash: And 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 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.   Dr. David Gandara Disclosures: Consulting or Advisory Role Company: Henlius USA, Foundation Medicine, Janssen Pharma, Merck & Co, Mirati Therapeutics, Regeneron, AstraZeneca, Guardant Health, Genentech, Exact Sciences  Research Funding Company: Amgen, Genentech, Astex Pharma  

We say thank you to current Cancer Stories host, Dr. Lidia Schapira, and welcome Cancer Stories new host, Dr. Mikkael Sekeres. TRANSCRIPT Dr. Lidia Schapira: Hello and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lidia Schapira, a Professor of Medicine at Stanford University, and with me today is Dr. Mikkael Sekeres, who is a Professor of Medicine and the Chief of the Division of Hematology at the Sylvester Comprehensive Cancer Center in Miami. In this episode, we will be discussing his new role as the host for the JCO Cancer Stories: The Art of Oncology podcast. Mikkael, welcome to our podcast and thank you for joining me today. Dr. Mikkael Sekeres: Lidia, what an absolute delight it is to be here with you. And I have to confess, it's also intimidating to think about taking this over from you, given the amazing job you've done over the past few years. Dr. Lidia Schapira: Well, thank you so much for that. This podcast originated as a bit of a dare. When Steve Cannistra, back in 2017, said ‘no' to some idea that I had for changing or expanding the section and issued the dare of why don't you do a podcast instead? And back in 2017, I had no idea. And we were less used to podcasts, so I trained myself. And then this beautiful new form sort of emerged just from my idea and dream of giving our listeners and our readers something new to chew on and to reflect on. Dr. Mikkael Sekeres: Well, it turned out to be prescient, didn't it? I can't tell you how many people I know, especially here in Miami, where we do tend to get caught in traffic and have a long commute time. I'm sure that never happens to you in Palo Alto. Dr. Lidia Schapira: Of course not. Dr. Mikkael Sekeres: But people listen to a lot of podcasts and it's a great way to catch up on personalities and on books and on the news. So good for you. I'm so happy you took the dare and ran with it. Dr. Lidia Schapira: Yes. And the first thought I had was to make it a bit artsy. So we started, for the first couple of years of rounding up everybody we knew who was an actor or had a voice that they used for their art or trade and asked them to read the essays or poems before we had the conversation with the author. Now, we have our own voice actor, so we know what we're going to get every week, and we're not looking for people and knocking on doors and asking very busy actors to donate their time. So it has evolved, as has the writing really. So I wondered if you can reflect a little bit on how you see this section both in the journal and also the conversations we're having in this podcast change and evolve over the years. Dr. Mikkael Sekeres: Let's be honest, we're both writers, right? So as a writer, you're always looking for an outlet for your work. And there aren't a lot of outlets in medical journals. Yet there's this huge audience of doctors and nurses and pharmacists and social workers who read these journals and have this incredible experience with this deluge of humanity we see every single day. So this is an incredible thing, that Art of Oncology was even created a couple decades ago and provided this outlet for people. And what I have noticed is that people have become more daring. So let's play on the dare that you took up to even start this podcast. They've become more daring in what they're willing to write about and in how vulnerable they're willing to be in print. I've seen this in my own career, in my own writing, where 20 years ago I came out of fellowship and very cautiously started to write about some of the experiences that I had. But it was cautious and used more professional language and didn't get into some of the vulnerabilities that we face in treating patients and that we experience in ourselves and in our colleagues. But I think people have been willing to share more of themselves, particularly in the last decade. Dr. Lidia Schapira: I totally agree with you. And one of the things that I've noticed is that we have younger writers and younger authors who are now taught, even during their medical training and postgraduate work, that writing as a way of processing emotionally difficult experiences or sharing interesting thoughts or coming together as a community is really important to create the kind of community of thoughtful practitioners that we need to sustain us while we do this difficult work. So we are having more and more submissions and published work from very young colleagues, trainees. And I find it very interesting, sort of this multi-generational way of expressing the contact with very ill patients and sometimes very moving to think back on the first time you gave bad news for those of us who may have done it a hundred thousand times. Dr. Mikkael Sekeres: So I think you're spot on about this. We're getting younger authors. We're getting folks who are early career, mid career. Now, we're receiving essays from folks who are at the end of their career and want to reflect on that career. And people we wouldn't have expected would write these vulnerable essays either. I wonder if some of the pieces we're getting from younger authors stems from the fact that fellowship programs are finally paying attention to the experience of being a fellow and being a trainee. Dr. Lidia Schapira: Oh, my goodness. It was staring at them all this time. I think when you were a fellow a long time ago, you were one of the advocates of having fellows talk to one another about their experience, right? Dr. Mikkael Sekeres: You have an incredible memory. During our fellowship, we started a Balint Physician Awareness Group. So there's this movement started by the Ballint, a husband and wife team to start to get healthcare providers to reflect on their experience and share that experience with each other to build a community of support. And we started this in our fellowship. And you can imagine the initial reaction to this among the fellowship directors was, “Why do you need that? What do you think you're doing? There's no place for that.” Dr. Lidia Schapira: “And we need our time to train them on the science.” This is maybe an extra. Right? I think many of us have felt that trying to advance anything that deals with humanism or the human side of providing care is considered maybe optional. And I think you and I have been pushing against that for a long time. Dr. Mikkael Sekeres: I think that's exactly right. What I think legitimized it a little bit is we got funding for it from The Schwartz Foundation. We then actually published a study looking at it in JCO because the fellows in our program spent time at two different hospitals. So it was by design, this crossover study where half the fellows got the intervention of the Balint group and half didn't. And it turns out, lo and behold, they actually felt better and had a better experience as a fellow when they had the intervention. Dr. Lidia Schapira: Yeah. It's so interesting that we had to turn it into a randomized control trial or whatever design you picked, but you needed to fit it into the section of the journal that respected the logic and process of scientific research. But that brings me to another point, I think, that we have talked about so much, but I think it's important for us to share with listeners. And that is that the section of the journal that we've created now, it used to be When the Tumor Is Not the Target, and we've shortened the title. The Art of Oncology is not a section for papers that address research or where there is no methods and results section. It is intentionally meant to be different from the rest of the journal. Is that how you see it, too? Dr. Mikkael Sekeres: Oh, my word. Absolutely. And our reviewers occasionally will have a submission that is more of a classic article in how it's structured, and our reviewers will push against it. And sometimes we're able to get back to the author and say, could you write this in a different way, something that's more reflective of Art of Oncology? I think it's meant to be, I don't want to say a break from the way other articles are written, but maybe a different style, a different way of using your brain and reading these articles. And we've seen that they're popular. Sometimes they are the most read article, even in JCO, in a given week, which, of course, we share with each other and gloat a little bit when that happens. Dr. Lidia Schapira: Yes, and it doesn't have to be the article that made you cry. It can also be the article that made you think. That's been my intention as the editor for this section for the last 10 years. I've tried to be very intentional instead of bringing to our readership articles that delve into different parts of this lived experience of giving care. Some are moving more towards ethical conflicts. Some are moving more towards the emotional labor of the work. But some bring out different voices and different perspectives. And I'm proud to say that the submissions we get really come from all over the world. So I wonder, Mikkael, as you're entering into this role now, your decade as editor for this section and host for our podcast is how you view the editorial process. How does your team help the authors bring their best article forward? Dr. Mikkael Sekeres: I took the lead from you, and I'm not saying that just to blow wind in your sail, but you have always given feedback to authors, whether it's a request for a revision and acceptance or turning a piece down. That's been helpful, that's been thoughtful, that's been empathic. And in the end, I know that your goal has always been with these reviews, to give the author advice moving forward. I've tried to take a page out of your book by doing that as well. I go into every piece you shared with me that you do the same thing. When I get a submission, I look at it and I'm so excited about what could be there, what truth this could reveal, what angle of thinking about something that I've never thought about before. And our reviewers go into it the same way as well. These are folks who have read hundreds, if not thousands of essays. They themselves are readers. They're writers. They've had submissions accepted to Art of Oncology. They're looking for pieces that reflect a great truth that we all realize sometimes it's a great truth that no one wants to talk about, and this is the first time somebody's talking about it. Those are the best pieces. When you read it and say, “I thought the same thing,” Or, “I had the exact same experience and no one's ever talked about it before.” We're looking for good writing. We're looking for pieces that are focused on a patient. And you and I have both given talks on narrative medicine. And one of the slides I have in my talk is to remind people that the patient is the most important person in the room and to make that piece focused on the patient's experience and, of course, the writer's reaction to that experience. But in the end, it's all about our patients and their experience. And we're looking for, as you mentioned, perspectives that we haven't seen before. So we want to hear from people who are in training. We want to hear from people in different stages of their careers, people who practice in different settings, people who bring different cultural backgrounds to their own perspective on the practice of oncology. Dr. Lidia Schapira: And if I may point something out to our listeners, you are an artist in being able to bring the bedside verbatims to the page and make them live. I've always admired that in your writing, Mikkael. Can you tell us a little bit about your process for writing and how the role of the editor varies or is different from the role of the writer? Because I've learned a lot about editing, and I think the editor is an interpreter, in a way. I'm fascinated. I was brought up in a household where we spoke four languages, and I was always fascinated by trying to find the right word in a language and struggling with all of that. And I think some of my love for editing, which is different from my love for writing or reading, comes from that, from trying just to find the right word or trying to respect the voice of the author and make it even better or more artistic. Can you tell us a little bit about your process and your relationship to language and writing and editing? Dr. Mikkael Sekeres: It's great to hear you come from a family where you spoke four languages. I am an unfortunate monoglot. I'm terrible with foreign languages. But I come from a family of English majors. My dad was a journalist for the Providence Journal in Rhode island, then an editor for 10 years. My mom was an English major as well. So I always think that as parents, our job is to impart one employable skill to our kids so they don't live in our basement forever. Dr. Lidia Schapira: That's what my father thought, and that's why I'm a doctor and not a philosopher. Dr. Mikkael Sekeres: We joke that we moved to Miami, so there is no basement they can live in. But I always felt in my family, the employable skill was writing. I grew up and when I went to med school, I think, we put on this armor of the language we're learning, and we're very uncomfortable and nervous about the skills that we have. So we use this language to separate ourselves from our uncertainty around medicine. I distinctly remember at one point talking to my parents and saying something that was very complex, using medicalese. And they said to me, “Why are you talking to us like this? We're your parents. You don't have to use that language. Just use language we can understand.” And that always resonated with me. That was kind of a North Star moment for me. That's what's guided my writing. And I have so much respect for the words that my patients use. And I think that's why I try to incorporate it in my essays as well. I always try to have my patient's voice literally there in their words as a focal point. I think as an editor, we go into a piece and we want to learn something. In the end, essays either educate or entertain, and ideally both. So we want to come out of a piece, we want to be either emotionally moved or we want to learn something and hopefully both things. And if I'm reading a piece as an editor and one of those two criteria have been satisfied, then I think it's a piece that's worth giving feedback to and advising revision. But I'm curious. I want to turn this a little bit, Lidia, because you're the one who always asks the questions. Dr. Lidia Schapira: I love asking questions. Dr. Mikkael Sekeres: So I'd like to ask you a question. When did you get started as a writer and a reader? And has that interest and skill changed over the course of your career? Dr. Lidia Schapira: Yes, I must say, I've always been a reader. That's my idea of heaven is a place with an enormous amount of books and a good espresso machine, just to give you an idea. So books have always provided companionship to me. They've provided community. I'm very happy living in a world of ideas, and I love art, and I love the sound of words and beautiful words put together beautifully. So that's basically reading and thinking, to me, are very closely aligned. And I also love and come from a culture, a society where conversation was valued. And I'm very sad that we don't anymore. We don't converse in our typical academic settings because we're so busy, and our language is mostly turned into units of efficiency. So I love the idea of communicating through language. Words, spoken words, things we listen to, things we read, things we write. My relationship to writing has been very undisciplined and inconsistent. And for all the years that I was an editor for this section, I found myself sort of inhibited from writing. And from the moment that I passed the baton on to you, I've been gushing. So I'm working on a book, and hopefully it'll be the first of several. But I've sort of kept my writing very private, and I've only been able to do it when I have a lot of time and no pressure. I'm not the kind of disciplined writer who can set aside time every day to write. I just can't do that. I need to be totally empty and free and be able to disagree with myself and erase a thousand words written on a page because they're just not good enough and start again. Dr. Mikkael Sekeres: I'm fascinated by that comment that you just made. What is it about being an editor that you feel has inhibited you from writing? Dr. Lidia Schapira: I think I was just busy. I was busy, again, immersing myself in the words that I needed to respond to and in the creative process of transforming essays into their best possible publishable form. And I think that's how I've interpreted the work of editors. I have tremendous respect for editors. I now need one to help me with my own work. But I think editors play an incredible role. And I am very happy that you view this role as something that is joyful. And I know that you have the amazing talent to do it. So I'm just very happy that we've made this transition. Dr. Mikkael Sekeres: Can I suggest that you've been giving as an editor also, because I think that your guidance to authors is precious? It's so valuable. Writers are so desperate to have that kind of caring advice. And I wonder if you've devoted all of your creative juices to doing that for the past 10 years at the expense of not being able to write yourself. So I'm so thrilled that you have the opportunity now. I will be the first person to buy your book, to write a review for your book. I can't wait to read it. Dr. Lidia Schapira: We've got a blurber. So now I need a good editor and a therapist, and I'm on my way. So on that note, I think it's time for us to end this lovely conversation, although we could go on for a long time. For our listeners. I want to thank you for having listened to me all these years, and I'm delighted that Dr. Sekeres will continue this wonderful program. And I look forward to listening while I drive, while I walk, and while I just simply am. Thank you for listening to JCO's Cancer Stories: The Art of Oncology. 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 of the ASCO shows at asco.org/podcasts. And thank you Mikkael. Dr. Mikkael Sekeres: Thank you so much, Lidia.   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.   Like, share and subscribe so you never miss an episode and leave a rating or review.   Guest Bio: Dr. Mikkael Sekeres is a Professor of Medicine and the Chief of the Division of Hematology at the Sylvester Comprehensive Cancer Center in Miami.  

Unlocking Emotional Strength Through Attunement and Support In a recent episode of Dads with Daughters, we had the privilege of hosting Dr. Tovah Klein, an esteemed professor at Barnard and author of the insightful book Raising Resilience: How to Help Our Children Thrive in Times of Uncertainty. Our conversation centered on the vital role fathers play in nurturing resilience and emotional strength in their daughters during challenging times. By delving into the essence of resilience, Dr. Klein offers invaluable advice on how fathers can become pillars of support and emotional stability for their children. The Essence of Resilience Understanding Resilience Dr. Klein defines resilience as the ability to adapt, adjust, and be flexible in the face of life's challenges. It is a critical aspect of a child's development, enabling them to navigate adversity with the emotional backing of their parents or caregivers. Rather than shielding children from every hardship, it's crucial for fathers to allow their daughters to face small adversities, helping them build coping skills and inner strength. Attunement and Emotional Stability Attuning to Emotional Needs Dr. Klein emphasizes the importance of fathers being emotionally attuned to their children. Emotional attunement involves understanding and responding appropriately to a child's emotional cues and needs. For fathers, this means managing their personal stress and emotional states to maintain stability at home. Children require emotional availability and unconditional love to build confidence and mental health, and fathers play a pivotal role in providing this foundation. Shifting Focus and Modeling Healthy Behaviors From Work Stress to Home Serenity A key recommendation from Dr. Klein is the necessity for fathers to shift their focus away from work-related stress before engaging with their children. Modeling healthy behaviors, such as limiting screen time and prioritizing family interactions, sets an example for children to follow. Fathers should strive to be present, listen, and engage in meaningful conversations during everyday moments like car rides or bedtime, turning these instances into opportunities for connection and support. Embracing Vulnerability Teaching Through Vulnerability Dr. Klein underscores the importance of fathers displaying vulnerability. By expressing a range of emotions and acknowledging their struggles, fathers teach their daughters that it's normal to experience and cope with various feelings. This modeling helps children feel validated and understood, fostering emotional intelligence and resilience. Practical Strategies for Coping Handling Academic and Social Pressures When addressing academic struggles or peer conflicts, Dr. Klein advises fathers to listen and validate their children's feelings rather than solve every issue for them. Encouraging daughters to learn from their experiences and take pride in their achievements, even during adversity, builds their problem-solving skills and resilience. Conflict with peers is natural and can lead to stronger friendships as children learn to navigate and resolve disputes on their own. Empowering Fathers, Empowering Daughters As fathers, the role you play in your daughters' lives is immensely significant. By being emotionally attuned, modeling healthy behaviors, and embracing vulnerability, you empower your daughters to develop resilience and emotional strength. These foundational skills enable them to face life's uncertainties with confidence and adaptability. For more resources on enhancing your parenting journey, visit Dr. Klein's website tovahklein.com, and consider joining support communities like The Fatherhood Insider and the Dads with Daughters Facebook group. Together, let's raise a generation of strong, resilient young women. TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:16]: Welcome back to the dads with daughters podcast, where we bring you guests to be active participants in your daughters' wives, raising them to be strong, independent women. Really excited to have you back again this week. As always every week, I love being able to sit down, talk to you, work with you, and walk on this path that you're on. And I call it a path. It's a journey. We're all on it together as we're raising our daughters to be that those strong, independent women that we want them to be. And it's not always going to be easy. There's gonna be bumps in the road. Dr. Christopher Lewis [00:00:46]: And but in the end, each and every one of us is working to try to help our children to be able to be self reliant. And one of the topics we're gonna talk about today, resilient as they get older. And every week I love being able to bring you different guests that can help you to do just that. Sometimes we have dads on. Sometimes we have others that have amazing resources that can help you to do just that. And today we've got another great guest with us today. Dr. Tovah Klein is with us today. Dr. Christopher Lewis [00:01:17]: And Tovah is a professor at Barnard, as well as we're going as well as a author of a new book called raising resilience, How to Help Our Children Thrive in Times of Uncertainty. I'm really excited to have her on and to introduce her to you. Tovah, thanks so much for being here today. Dr. Tovah Klein [00:01:40]: Oh, thank you for having me. I'm excited to be here. Dr. Christopher Lewis [00:01:42]: Well, I'm excited to have you here as well. Because as you heard, this podcast is all about raising strong, independent women. And part of that is being able to give our kids the keys to, well, I'm gonna say the castle in regards to helping them to be resilient in the things that they're going to come up against. And there are definitely going to be things that they're going to come up against. And there's some of those are gonna be positive. Some may be negative and some may be somewhere in between. And I'm really excited to be able to delve a little bit deeper into this book that you've put out into the world. But I think I wanna step back in time just a little bit. Dr. Christopher Lewis [00:02:16]: And first I wanna have you define resiliency because you know, this book is called raising resilience and every person that hears that word resilience may have a different thought in their mind of what that means. And then I'd love to hear your origin story. I wanna hear why this topic and why you wanted to put all the time, passion, effort into putting this out into the world? Dr. Tovah Klein [00:02:37]: So when I think of resilience, what I really think about is the whole person, the whole child. And resilience is not like a trait or a dose or something that you say, you know, I'm 1 or I'm a 6. It's actually a part of who we raise our children to be. It's about adaptability, adjustment, flexibility. You can think of it as opening up their thinking, but it's being able to move with whatever life gives them. And as you just said, life's gonna give them good and not so good. And so, really, when we think about preparing our children for life, we love them, We do all kinds of kind of things for them, but really what we want is for them to be able to handle the hardest parts of life, and that's what we call resilience. It's a process to help them develop it, but also that adjustment, adaptability, flexibility allows them to face hurdles and shift, face hurdles and shift, knowing that they're not alone in the world. Dr. Tovah Klein [00:03:38]: They're not doing this themselves, but with originally a parent or whoever is the main caregiver, and then in life, other people who can be there for them. So that's really how I think about resilience is this dynamic piece of self that gets developed over time. Actually, I've been in the field for almost 3 decades now working first with young children and parents, and my research was always centered around young children and that really important influence of parents on them. And then as careers change, I started working with, you know, older children and parents, and that just broadened my thinking. And one day came to this sudden realization that really what parents were doing is helping children prepare for uncertainty. Like, every single day is uncertain. And I have kind of 2, I would say, areas that I'm passionate about and I've spent my life in. One is kind of everyday, normal development challenges, stressful moments. Dr. Tovah Klein [00:04:41]: And then the other piece, which I always saw as related, was working with families in traumatic situations, so either individual trauma from, you know, abuse or hurts, or fleeing a fire or a flood, but also collective trauma. So children and families after 911, I've done work now in COVID, which when I started conceptualizing the book, I had not yet, but, you know, sort of large scale traumatic events. And when I put those 2 together, I realized that the piece that happens in trauma, whether that's a severe crisis and you've just fled a hurricane and those roads washed out, or you're getting through a normal day with 3 children of different ages and you're trying to get out the door, you're always dealing with uncertainty, and it's very destabilizing. And then that what I got to is, like, oh, then what we're doing every single day in our relationship with our child, whether we know it or not, is helping them prepare for life, which is gonna unfortunately have bad things happen in it, and we want them to be able to handle. We want them to be able to people to turn to. So the book started out really about uncertainty, wrote a proposal, kind of put it aside, you know, life gets in the way, work gets in the way. Then when COVID hit, it really became very clear to me that uncertainty was here to stay, or I thought it was here to stay, and I felt like I needed to get back to this book. But when I started writing, and my contract, you know, got a contract with HarperCollins, the editors kept saying to me, you know, everything you write about is about resilience. Dr. Tovah Klein [00:06:13]: And I pushed back saying, you know, that's really a buzzword. And I'm not interested in that. I'm interested in writing a book about how do we raise decent human in writing a book about how do we raise decent human beings? What does that mean for parents? Dr. Tovah Klein [00:06:19]: What does that mean for children? And what I meant by that was children who grow up with a strong voice and ability to take care of themselves and have confidence and, equally, an ability to look to others and be kind and compassionate and aware of their community. And they said, yes, but everything you're writing about is resilience. And so I said, okay. I'm gonna take it out of that buzzword, and I'm gonna really unpack what does resilience mean, and what does that parent relationship or caregiver relationship mean in terms of raising that child because so much of this is about us as parents, and that had been the life work I've been doing is really studying and working with everyday parents to understand what we bring to this as parents, because that then drives how we see our children, how we either do or don't accept them for who they are, and children have to be accepted for who they are. And so what's the work we we must do on ourselves to understand ourselves so that we become that buffer between the world and what the world gives us and children so that there's stress, but it's not overwhelming stress for children. And that's really how this book came to be. Dr. Christopher Lewis [00:07:37]: Now one of the things in the book that you talk about and that you emphasize is the role of parental attunement in building resilience. How would you say that fathers in particular can attune to their children's emotional needs during challenging times? And what specific strategies can they use to be more emotionally available? Dr. Tovah Klein [00:07:58]: Yeah. It's such an important question because, you know, as you know, as a father and a and a podcaster with fathers listening, for so long, the field of psychology didn't even know that fathers existed, or they were sort of like, oh, yeah. But we know now from experience and equally from the research that a loving parent matters and fathers matter. And so this idea of attunement, particularly when times are stressful, really means starting with self. And I think the the challenge for some dads, I think not always, but is that boys are raised into becoming men who aren't really taught or told, oh, you're supposed to feel feelings. Feelings are okay. This this is human. And so doing the work to say, oh, how am I doing? How am I feeling? Can I ground myself as a dad so that I can turn to my child and figure out what my child needs? Because often as parents, when we're upset, we go for control. Dr. Tovah Klein [00:09:00]: Right? If I'm feeling really rattled, if there's a lot of uncertainty, every parent, male, female, non binary, like, every parent who feels unsteady kind of we kind of go for, what can I control? And when you take a step back as a dad and you say, okay. I'm the one who's stressed here. How can I get a little steadier so I can turn to my child and then say, what does this child need for me to protect them right now? Not protect them by keeping everything out, but by saying, right now, we're not sure what's happening. People are getting sick and we're not sure why, but what I know is that by staying home, I'm gonna keep you safe, and we're gonna still have our meals together, and I'm gonna still put you to bed. It reassures a child that even when there's bad things going on, this parent is close to help them, and that's what children need. We always think of it in young children. Children need it across ages, for us to say I'm here for you even though this is scary or stressful. Dr. Christopher Lewis [00:09:59]: So some of what you were just talking about, those emotional barriers or the walls that sometimes some men put up, it's not always easy for some men to break those down. And to be, as we've talked about on the show before, is vulnerable with those around them. And from what you just said, really, to me, what I'm hearing is the importance of being vulnerable and showing that vulnerability with your kids. Because by showing that vulnerability, it equates to allowing and providing your kids a glimpse of resiliency in many different ways. Dr. Tovah Klein [00:10:36]: Yeah. You'd summarized that very well, actually, which is we have to be vulnerable in order to say, oh, what am I feeling? And, you know, I read something recently that said being vulnerable is the opposite of cool, you know, being cool. Because being cool is kinda putting on, like, armor of some kind. Like, you know, I got this. You know, I'm a cool person. Being vulnerable says, I'm gonna show you and myself all of me. And all of me is not always parts that we're proud of or that we feel good about, but they're part of us. So right now, you're a father and something's going on in your life or in the world, you have to say, look, I'm a little scared, you know, to yourself or to a partner or to a friend. Dr. Tovah Klein [00:11:18]: I'm a little scared, but I know I have to take care of these children. So I'm gonna figure out what that's about so I can turn to my child and say, yeah. This is unknown, and we're gonna figure it out together. And it's that vulnerability that allows us to be full people. What it shows to the child is it's okay to have this range of emotions, of, you know, reactions, and that that's life. Life is not about covering up how you're feeling. Life is not about pretending. Oh, no. Dr. Tovah Klein [00:11:49]: No. No. I'm not upset. It's just the opposite. It's saying, you know, I am upset. And even if I can't do what I wanna do, I know that daddy is gonna love me even though I'm upset right now. And so when fathers model that, children go, oh, it's okay to fall down, to fail, to feel really dumb. Whatever it is, it has to be modeled for them. Dr. Christopher Lewis [00:12:13]: Now also in the book, you talk a lot about how adversity can actually make children more resilient. Can you share some examples of how fathers can help their children to reframe difficult situations? And it could be something like it could be peer conflict, it could be academic struggles, it could be other aspects that they're going to run into. Dr. Tovah Klein [00:12:36]: So I think, you know, one of the biggies on the academic side is, you know, your child comes home, your daughter comes home from pick a grade and says, like, I'm just stupid. I can't do math. This is very stereotypical and yet happens all the time for girls, for adolescents and younger girls. I'm stupid. I can't do this. You know, and as a dad, you might think, oh, maybe maybe I shouldn't push her to take that harder math that she wanted to take. You know, maybe I should just say to her, oh, honey, you know, you don't have to take algebra, advanced, or whatever it is. Instead, you can say, like, yeah, that is hard, and learning is a hard process, and be there with them. Dr. Tovah Klein [00:13:15]: So some of it is listening. You know, we tend to want to problem solve. I know, there's all kinds of jokes about, you know, men and dads wanting to problem solve, but I always say, well, moms do that, too, you know, but, you know, that's sort of the stereotype of, of males. And what we don't do as parents well enough is listen. So it may be listening to your daughter really cry, scream, tear the paper up if they still have paper tests, and then say, yeah, this is there's no question this is hard. Maybe you recall a story from your own. Oh, yeah. I remember when I got to quadratic equations, and, woah, I thought I'm the dumbest person in the world, but I wasn't. Dr. Tovah Klein [00:13:54]: And it's holding them through that, allowing them to have all of those emotions, and then some sense of tomorrow might be better is what I call it. Right? So let's see how it goes tomorrow. Do you wanna talk to the teacher? Tomorrow, you're in the moment. It's like, no. You know? They just wanna vent, and you let them vent. But the next day when they go back to school, they may actually come back and say, hey. I got my test back, and I didn't do well, but I didn't do the worst. Or I got problems right. Dr. Tovah Klein [00:14:21]: I was sure I got wrong. You go, oh, really? What you learned from that? Oh, okay. And you have to have this, like, almost like a humorous distance. Right? You don't wanna say I told you so or I knew it, but you can say, yeah. You know? That's gotta feel great. So what are you thinking next time? Or if you wanna think through studying differently, let me know. And then the child builds on that. Oh, I actually didn't do as poorly on that test as I thought. Dr. Tovah Klein [00:14:48]: The dad wasn't there going, oh, it's only because you were tired. Like, we love to make excuses for our children. We either blame them, like I told you to go to bed earlier, or we make excuses. Oh, remember you weren't feeling so well. And all of that works against a child saying, I faced something. It was hard. I don't love my score in that test, but I'm actually proud of the things I did get right, and I'm gonna study a little differently next time. That's strength. Dr. Tovah Klein [00:15:14]: Fighting with friends, children do it all the time. And in fact, the data we have with younger children is that they fight more with the people they're closest to. So they don't really fight so much over, you know, building a block tower or how to organize the playground game if it's somebody they're not friends with because it's not worth their energy. But they can get into pretty heated fights with people that they're friends with or that they play with a lot, and then they come back together. Why? Because they want to. The motivation is I might have thrown you out and said I never wanna see you again or talk to you again yesterday, but today, you're my friend again. And it's even stronger because we've been through this conflict, and we've we've resolved it. And so I think as a father to know that it's not about the problem solving, but to to listen, to say, hey. Dr. Tovah Klein [00:16:09]: If you want my help, I'm here. But to recognize that you have to wait for the child to come in and say, I really do wanna play with her tomorrow. Oh, okay. Well, you know, do you want wanna think about what helped you last time with that friend and and to talk it through. And I see it all the time now with with social media and teenagers. You know, when I hear my kids or my college students, I teach at a women's college, so I have all these incredible young women. You know, that term ghosting, which was new to me in my generation probably shows, like, what? But with ghosting, it's almost like there's a brick wall. And so sometimes I say to a teenager, like, is there a way to take a step back and maybe try another day to reach that friend? Because it sounds like that really was a friend. Dr. Tovah Klein [00:16:55]: So it doesn't have to be the message is this doesn't have to be forever. And I think dads have to give that message when it's appropriate. Right? You're really heated now, but I'm wondering if in some time and initially, the the child goes, no way, but then they may come back to you and say, yeah, I was thinking about what you said. Dr. Christopher Lewis [00:17:11]: You know, one of the things I was thinking about, and it kinda goes into some of the things you wrote too, was the fact that more and more you hear today about the mental health concerns in young people and the rising concerns about mental health and the struggles that young people are having. What would you say to fathers about how they can contribute to create a supportive environment at home that fosters both emotional intelligence and emotional component. You know, I say it in my book, these 5 pillars, but the first is building trust, right? That's what every father is doing with their child. They're building trust in this relationship. Like, even when things go awry between us, I'm here for you. You know, putting your child to bed at night or going into check on your teenager really can be about, boy, we had some rough spots today, and you know, I'm sorry, and I still love you. All of those disconnections that get repaired, reconnecting are really core for our children and particularly, I'm gonna say, for our girls, because they need to know conflict is part of life. That's where you get this emotional attunement, which is, yeah, we were angry before, you were really mad at me, and now we're back together, and we're good. This is part of it. You're not, like, overlooking it. Dr. Tovah Klein [00:18:40]: But I think the other piece at home is that we tend to put a lot of pressure on our children, particularly firstborns. Not always, but particularly firstborns. Right? They're our first ones. They make us a parent. You know what I'm saying? Before that first one, there was no such thing as I'm a parent. Now I'm a daddy. You might have subsequent children, but the first ones are kind of our reflection. They go out in the world, we feel great when they're doing well, and we like smile. Dr. Tovah Klein [00:19:06]: And then when they're not doing well, we're like, we feel terrible, but also, we tend to blame them. Don't do it that way. So I think for dads to really think about, when am I too hard on my child or my children, and when am I putting too much pressure on them? Because we live in a very competitive world, you know, certainly academically and just there's all this messaging about mental health, which we should be concerned about. But there's equally messaging about, there's only one way to get to the top, or if you're not at the top, you won't succeed. And it's a total lie. It's just a lie. And I feel like if every per parent, every dad could say to their child, there's lots of ways to be okay in the world. You know, some people are really great at sports. Dr. Tovah Klein [00:19:50]: Some are really great at math. Some just enjoy it. Like, we've taken the joy out of learning or doing. So I think at home to really think about, can I bring the pressure down? Can I find moments of joy together? Like, you're much better off having a dance party, if that's what your children like to do, or have a backwards dinner. This is I grew up with backwards dinners occasionally, and they were just such a joy, or can we take a different path to get to where we're going today, and who wants to map it out? And even if you get lost on the way, that's funny. That's really funny, you know. So where can you have those moments of shared joy, and then I'm gonna get back to listening. We don't listen to children. Dr. Tovah Klein [00:20:29]: They're not busy people. Dads are busy. Maybe you have work or maybe home is work. You've got a couple of kids or you've got one who's got some special needs right now and you're trying to figure those out and you're taking them to different therapists. Whatever it is, we're busy. And what gets lost is what I call the space in between, which is like getting there. You know, maybe that's in the car or it's, you know, you walk to school or to a doctor's appointment or something. In those moments, there's a lot of time to connect and listen to your child. Dr. Tovah Klein [00:20:59]: And so putting more of that in or thinking, like, do I really wanna rush through bedtime with my 8 year old? Or can I slow it down and so they go to bed 10 minutes later? Anything at home that brings down the pressure and gets parents to exhale and the dads to say, just wanna connect with you. I don't really care what you eat for dinner. I'm gonna serve it. I'm not gonna take it personally if you don't need it, and I'm gonna listen to you today. So the lighter we are with children, the better. And it also opens them up to talk more. And we say, you know, we ask them questions, they shut down. They're like, I'm not answering you, daddy. Dr. Tovah Klein [00:21:32]: But when we sit down at dinner and say something funny that happened I I'm just thinking of my husband used to sit down and he'd go like, I'm gonna tell you the funniest thing that happened today. And it would just be this, like, beat fact of some kind. Then the children would start talking because nobody asked anything of them. Dr. Christopher Lewis [00:21:47]: Earlier, you talked about fathers trying to protect their kids. And I think that the word protect means different things for different men. But I guess one thing that I think that many men feel is that they need to protect their kids from hardships, from that they need to protect them from getting hurt. How can fathers reconcile that instinct with some of the approaches that you're talking about, about allowing kids to face adversity as a means of building resilience? Dr. Tovah Klein [00:22:20]: So much of this is about work on themselves. Right? Of course, we wanna protect our children. There's a part of any dad in particular because what's the function of a daddy to love a child and keep them safe? And to say, you're not gonna always be with them. You're not gonna always be there to protect them. So what can I do to help them deal with the little hurts and the smaller hurdles and the smaller adversities now is to back off and let the child deal with them? So, I'll give an example. You know, that term bully gets used a lot. Now, there are some children who really are victims to being bullied, but every child potentially is going to have meanness in their life from other children and from themselves, by the way. I think we do a disservice when we tell children that's mean, that's mean, that's mean because it scares the child. Dr. Tovah Klein [00:23:09]: Well, what if I don't like my friend today? And then am I a horrible person for telling them I don't like them? No. They're not horrible people. They may be standing up for themselves. So when we step back, and if a dad steps back and says, what's worrying me so much about my child getting hurt? Because every dad brings their full self to being a dad. And so it's really about saying, what's the really, what is the harm that I'm worried about? And usually, it's I remember how bad that was being left out, or I was terrible at athletics, which is takes in a whole other life for men than it does for women, right, because boys are supposed to be athletic. Right? So if you were that child who was left out or you were that kind of outsider peer who didn't really feel like you belonged, we then get more worried for our children, and we jump very quickly. So I think being aware of self, and that's what I call in my book, The You Factor, those are I have all these reflective questions there for dads, for moms, for anybody taking care of children. What is it that I bring? Because when we don't give children this opportunity to handle the smaller hurts, even when the child thinks they're big hurts you know, my friend wouldn't play with me today. Dr. Tovah Klein [00:24:22]: He starts young and goes all the way through adolescence and then becomes part of social media. But to say, yeah, that's really crummy. Sometimes that happens. And to have some empathic, but genuinely empathic, but also, I'm gonna sit by you, but I'm not gonna take this away. I'm not gonna march up to the school and speak to the teacher unless I hear it as a pattern and I'm really getting concerned. Or as I often say to to a parent, you know, to a dad, just check-in with the school and see what the school says, if it's a school that, you know, you're comfortable with or the counselor, you know, the the middle school or a high school counselor. But when we don't let children deal with these smaller stressors, hurts, you know, not doing as well as they wanted, not getting the teacher they wanted, but then they might actually find that teacher is not so bad. It actually strengthens children to say, hey. Dr. Tovah Klein [00:25:13]: I got through that. I figured that out, or I didn't like that teacher because she yelled more than I liked, but, actually, she was a really great teacher, and I learned to deal with the fact that she yelled a lot. That's where strength comes from, that children see people are complicated. And I think as dads, the role is to help them see, yeah, people are complicated. Maybe your friend had a bad day today. Doesn't mean she should've been like that with you, but maybe she had a bad day. Do you wanna see if tomorrow's better? Gives them a world view of, you could have a bad day, and I don't want people vilifying you, and other people also are sometimes hurtful. That doesn't mean they're hurtful all the time, and that strengthens children. Dr. Tovah Klein [00:25:53]: The other thing it does is it helps them use voice. If you never face adversity, you never have to say, hey. I don't agree with that, or you can't do that to me. And I actually think that this huge part of resilience, which is confidence and the ability to stand up for yourself, comes from learning to do it, and it starts off in smaller ways. I well, now I said I didn't wanna play basketball today, and then I basketball today, and then I finally walked away. I just said I'm not gonna play. It's a smaller way to use voice because when people are doing things to you that you don't like, we wanna be sure that our children, the daughters say, absolutely not. You can't do that to me, and not feel like I'm being a mean person. Dr. Tovah Klein [00:26:31]: We do give them double messages, particularly to girls. Be nice. Be nice. Now stand up for yourself. And I see girls getting confused with that. And it's like, well, actually, you can do both. You can be a kind, decent person, and that's not in opposition to saying no, or I don't like that, or can we talk about this. Dr. Christopher Lewis [00:26:50]: So what I'm hearing you say is that there really are a lot of tensions, a lot of things that can impact a child in many different ways, whether it be familial tensions, whether it could be tensions from outside the home, whether that that are impacting the child directly, or even world events that may be causing strife, and are impacting your child, whether you like it or not, as as you're thinking about that, or how can fathers take a proactive role in addressing those external those external stressors while still being able to maintain some sense of stability? Some some sense of some sense of stability at home? Dr. Tovah Klein [00:27:36]: Yeah. I mean, that's a big question, obviously. You know, what are those stressors? But I'll start with sort of the innermost or the most intimate, which is your personal stressors. And here's your first level of uncertainty. Like, we change. You know, dads change. You might be calm at some days and a little more frantic or a lot more frantic others. So part of that is being truly in tune with self as best you can and not being hard on yourself when you're not. Dr. Tovah Klein [00:28:06]: So, oh, I'm stressed. Why am I stressed? And then what can I change? Sometimes you can. Sometimes you can't. But I find that more often than not, a dad could change something. Yeah. You know what? I keep saying that I can't bring the work stress down, but I'm gonna have to, and I'm gonna find a way, or I am gonna help ask for help. If there's a group of people who probably don't ask for help enough, it's parents, and then dads on top of that. Right? They don't say, hey. Dr. Tovah Klein [00:28:33]: Can I ask my neighbor to take my child to the bus stop or pick my child up today or, you know, I'm gonna be late for my child's band concert? Could you let her know I'm still coming? Right? So any way to turn to others for help can help. But then there's the wider world, and that's a lot of self work. I mean, there's a lot going on in the world that is scary. There's no question. And with news being 247 in in our faces, I think it's up to us as the parents. So to the dads to say, okay. I'm a news junkie. I've gotta take some of these notifications off my phone. Dr. Tovah Klein [00:29:11]: I've gotta come up with a way that when I walk in the door and I've got children now to connect to, I've gotta find a place to put my phone. And by the way, that's modeling for when your children have their own phones. It's very hard to say to children, when we walk in, we put our phones here if the dad doesn't do it, because they just call they'll call you out right away. You don't do that. So it's becoming aware of what's stressing you, what's scaring you, and how can you shift in dealing with it. It's a very intentional process. How do I get my feet planted? How do I exhale? 1, I'm just thinking of a dad I worked with for years, and and the first time he called me, he said, you know, I manage this huge group of people. He's in construction, this huge group of people, and I tell them what to do. Dr. Tovah Klein [00:29:56]: And I'm, you know, in the car driving home telling, you know, putting out fires or whatever. And then I get home and no one listens to me, and I said, can you put the phone down, like, a mile away so that the last part of your drive, you're shifting focus? And then when you get to the door of your house, you exhale and say, I'm going in now, to 2 children who won't listen to me. So you're literally intentionally exhaling, switching modes, and getting some humor because that actually that calm or calmer it doesn't read perfect calm is felt by the children, and they feel they feel that dad walking in the door. They feel that dad who's stressed at the dinner table, and so it's really a very intentional process. And again, I think it's something that men in in particular are not raised with. Like, you are gonna be the emotional sustenance for your children, and you are. And so to take that in and say, wow, what a privilege, what a great thing, and wow, That means I have to be aware of myself because the more emotionally attuned a dad is, particularly for those daughters, the more they feel loved and respected. And in their worst moments, they really need to feel that. Dr. Tovah Klein [00:31:10]: Like, I really messed up. They wanna know that this is unconditional love. I still love you. Yeah. That was a mess up. We're in this together. I'm not gonna leave leave you or abandon you because you had a, you know, rotten day or set of events, And that's what bolsters mental health too. I'm loved even when I'm my worst self for the children. Dr. Christopher Lewis [00:31:30]: Well, Tovah, there's a ton to unpack here, and I really appreciate you coming and talking about all of this. And I know that, this book can definitely help so many fathers and mothers and parents in general to better connect with their kids, but also help their kids in a lot of ways. If people wanna find out more about the book itself, where's the best place for them to go? Dr. Tovah Klein [00:31:56]: Yeah. Well, the easiest place is to go to my website, Tovahkleen.com. That's Tovahkleen.com. And the book is sold wherever books are sold. So you can get online at your local book store. And if you go to my website, you've bought the book, you just put in your receipt, whatever receipt it is, and there's a free download for something that I call the UFACTOR journal. And that's all the reflective questions from the book and a place to either write out answers or just have the questions there to reflect on. And I will say I got an email this week from a couple who wrote to me and said that a mom and a dad couple, were doing the reflective questions together and then coming together and discussing them, and it's been good for our marriage. Dr. Tovah Klein [00:32:42]: So I thought, oh, that's really great. Because reflecting on self makes you a stronger person, which makes you a better dad. No question. And shedding vulnerability, because sometimes reflecting on yourself does not feel so great. Dr. Christopher Lewis [00:32:53]: So true. Well, I truly want to say thank you. Thank you for writing this and helping parents to connect with their kids in this better way, but also for sharing this with us today for being here and for challenging us to think about resilience in a different way as well. And I wish you all the best. Dr. Tovah Klein [00:33:14]: Yeah. Thank you for having me. Dr. Christopher Lewis [00:33:15]: If you've enjoyed today's episode of the Dads with Daughters podcast, we invite you to check out the fatherhood insider. The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step road maps, and more, you will engage and learn with experts, but more importantly, dads like you. So check it out at fatheringtogether.org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with daughters is a program of fathering together. We look forward to having you back for another great guest next week all geared to helping you raise strong and powered daughters and be the best dad that you can be. Dr. Christopher Lewis [00:34:14]: We're all in the same boat, And it's full of tiny screaming passengers. We spend the time. We give the lessons. We make the meals. Dad you can be. You're the best dad you can be.

Prioritizing Presence Over Presents As we approach the holiday season, the hustle and bustle of gift-giving can often overshadow what truly matters—being present. Just a reminder to cherish moments with our children, whether that's through family traditions, snowy escapades, or heartfelt conversations. These memories are the true treasures that shape our daughters' lives. Taking a Meaningful Break We will be taking a short hiatus for the podcast and I encourage you to immerse yourselvef fully in the season's magic. This is definitely not the end of the podcast, but a chance to recharge and return with renewed energy and insights in the new year. Resources for Reflection and Growth To continue your growth as a dad even during the break, I suggest youo explore the Fatherhood Insider resource. This platform offers an extensive course library, interactive forums, and actionable roadmaps tailored for fathers navigating the complexities of parenthood. Join the Community Don't forget to connect with fellow dads by joining the Dads with Daughters Facebook community. It's a space to share experiences, seek advice, and find inspiration from other fathers who are equally committed to raising empowered daughters. Check the podcast notes for a direct link. Embrace the Joy of Fatherhood This holiday season, let's focus on the laughter and love that fill our homes. Appreciate the simple moments and remember that being a dad is a gift that keeps on giving. Happy holidays from the Dads with Daughters family to yours.   TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:15]: Hey, Hey, everyone. Welcome back to Dads with Daughters, where we bring you stories, tips, and inspiration for raising strong, independent women and helping you to be the best dads that you can be along the way. I just wanted to take a moment to connect with you as we approach the holiday season. It's such a special time of year. And if you're like me, it's also a time to reflect on what really matters, family, friends, and those precious moments we get to spend together. This season, I'm making it a priority to be present with my loved ones, and I want to encourage you to do the same. Whether it's watching holiday movies with your daughters, building a snowman, or just sitting down for a quiet conversation. These are the memories our kids will carry with them forever. Dr. Christopher Lewis [00:01:03]: To give myself and all of us a chance to really soak in the magic of the season, Dads with Daughters will be taking a short break over the next few weeks. Don't worry, we'll be back in the new year for more amazing guests, stories and insights to empower you in your fatherhood journey. Until then, I want to wish you and your family a truly joyful holiday season. May it be filled with laughter, love, and those simple moments that remind us why being a dad is the greatest gift of all. Thank you for being a part of this incredible community. Your support, your stories and your dedication to being present with your daughters inspire me every single day. Take care, be safe, and from all of us here at Dads with Daughters, happy holidays. If you've enjoyed today's episode of the Dads with Daughters podcast, we invite you to check out the fatherhood insider. Dr. Christopher Lewis [00:01:58]: The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step roadmaps, and more, you will engage and learn with experts, but more importantly, dads like you. So check it out at fathering together dot org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with daughters is a program of fathering together. We look forward to having you back for another great guest next week, all geared to helping you raise strong and powered daughters and be the best dad that you can be. Dr. Christopher Lewis [00:02:50]: We're all in the same boat, And it's full of tiny screaming passengers. We spend the time. We give the lessons. We make the meals. We buy them presents and bring your a game. Because those kids are growing fast. The time goes by just like a dynamite blast, calling astronauts and firemen, carpenters, and musclemen. Get out and beat the world to them. Dr. Christopher Lewis [00:03:37]: Be the best dad you can be. Be the best dad you can be.

JCO PO authors Dr. Philippe Bedard (Staff Medical Oncologist at Princess Margaret Cancer Centre and Professor of Medicine at University of Toronto) and Dr. Alberto Hernando Calvo (Medical Oncologist at Vall d´Hebron University Hospital) share insights into their JCO PO article, “Combined Transcriptome and Circulating Tumor DNA Longitudinal Biomarker Analysis Associates With Clinical Outcomes in Advanced Solid Tumors Treated With Pembrolizumab,” one of the top downloaded articles of 2024. Host Dr. Rafeh Naqash and Drs. Bedard and Hernando Calvo discuss how combined transcriptome and ctDNA longitudinal analysis associates with pembrolizumab outcomes. 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 we are excited to be joined by Dr. Philippe Bedard, Staff Medical Oncologist at the Princess Margaret Cancer Center and Professor of Medicine at the University of Toronto, as well as by Dr. Alberto Hernando-Calvo, Medical Oncologist at the Vall d'Hebron University Hospital, both authors of the JCO Precision Oncology article titled, “Combined Transcriptome and Circulating Tumor DNA Longitudinal Biomarker Analysis Associates With Clinical Outcomes in Advanced Solid Tumors Treated With Pembrolizumab.”  Thank you for joining us today. Phil and Alberto. Dr. Alberto Hernando-Calvo: Thank you. Dr. Philippe Bedard: Great to be with you. Thanks for having us.  Dr. Rafeh Naqash: One of the reasons we do this podcast, as some of the listeners who listen to this podcast regularly may know, is to bring in novel approaches and try to understand how the field is moving towards a space where we are understanding biomarkers better. So your manuscript that was published in JCO Precision Oncology fulfills many of those criteria. And interestingly enough, I was at a conference at the Society for Immunotherapy of Cancer last month earlier in November and a lot of excitement at SITC was revolving around novel transcriptomic biomarkers, proteomic biomarkers or imaging based biomarkers. So could you tell us a little bit about why you started looking at biomarkers? This is an extremely competitive field. Why did you think that looking at the transcriptome is somewhat different from or more interesting from tumor mutational burden PDL-1 than other biomarkers that we currently use? And that question is for you Alberto to start off.  Dr. Alberto Hernando-Calvo: So I think gene expression profiles may have a predictive performance as compared to already existing biomarkers and this was one of the points that we describe in our manuscript. The gene expression signature that we developed back in 2019 at Vall d'Hebron Institute of Oncology was initially developed based on over 45 different tumor types and tested in over 1000 patients treated with antiPD-1 and anti PDL-1. And back then and in this manuscript, we proved that for instance the gene expression signature VIGex that we developed has a potential complementary role to other predictive biomarkers. In this case, we observe this predictive power with ctDNA dynamics and we then see a correlation with other existing biomarkers such as tumor mutational burden. So I don't think we need to use one or the other, but rather they may have additive predictive power. So we need to better individualize predictive biomarkers based on tumor types and select the best combination possible to improve the performance.  Dr. Rafeh Naqash: I completely agree that one size does not fit all, especially in the landscape of immunotherapy. From your perspective, when you developed the original signature, how did you choose what genes to look at? I looked at the manuscript, on the methodology side, some of the signatures are pro-inflammatory STING interferon gamma based, so how did you try to identify that these are the 7 to 10 or whatever number of signatures on the transcriptome side? And then why did you try to combine it with ctDNA based changes?  Dr. Alberto Hernando-Calvo: Back in our initial manuscript, published in Med from Cell Press, we developed the VIGex gene expression signature, as I mentioned, with taking into consideration over 1000 tumor samples from FFPE that we can consider real world samples because they are from real patients coming from the clinic notes as part of real investigational protocol doing or performing biopsies on patients. We did observe after doing a VIGex research and doing different tests, we eventually collected these 12 different genes. Because there is a combination of both genes involved in the interferon gamma pathway, we have genes associated with Tregs as well as T cell memory cells. So it's not only looking at genes that are associated with T cell activation or CD8+ T cell infiltration, but also looking at genes that may be overactivated, overexpressed, an immunosuppressive tumor microenvironment. So it was both selecting genes, the minimum number of genes to do it more scalable and having the minimum dataset of genes and including in the signature genes that are already at targets for immune sequent inhibitors or are being tested in immunotherapy combinations.  Dr. Rafeh Naqash: Thank you. And Phil, for the sake of our listeners, could you elaborate upon this aspect of using ctDNA? So this was tumor-informed ctDNA from what I understood in the manuscript. You guys basically try to use it to understand changes in the ctDNA with treatment and then try to combine it with the transcriptome signature. How did the idea come up initially and how did you plan on combining this with an RNA-based signature? Because I have seen manuscripts and other data where people are either using one or the other, but not necessarily both together. So how did you guys come up with that idea? Dr. Philippe Bedard: Well, we thought that this was a great opportunity to look at the combination of the transcriptome as well as the ctDNA dynamics because we had run an investigator-initiated phase 2 clinical trial called INSPIRE at our institution at Princess Margaret from 2016 to 2018, where patients across five different tumor groups received single agent pembrolizumab. And we really did a deep dive on these patients where there were tumor biopsies before and while on treatment. We did exome sequencing, we did RNA sequencing to capture the transcriptome. And in a prior analysis, we had partnered with Natera to look at their Signatera assay, which is a bespoke ctDNA assay, to look at ctDNA dynamics using this test and the association with response outcomes as well as survival outcomes. So we thought that this was a really unique data set to try and address the question of whether or not there was complementarity in terms of looking at the transcriptome and transcriptome signatures of IO benefit together with the ctDNA dynamics. Dr. Rafeh Naqash: From a patient treatment standpoint, it sounded like you mostly tried to include individuals who were treated with pembrolizumab. Did this not include individuals who were treated with chemoimmunotherapy or chemotherapy with pembrolizumab? Just pembrolizumab alone? And if that's the case, some of the tumor types there included, from what I remember, ovarian cancer and some other unusual cancers that don't necessarily have approvals for single agent pembrolizumab, but perhaps in the TMB-high setting. So can you elaborate on the patient selection there for the study?  Dr. Philippe Bedard: Yeah, that's a great question. So at the time that the study was designed in 2015, this was really the early days of immune checkpoint inhibitor therapy, so we didn't have the approvals that we have now in specific tumor types for immunotherapy and chemotherapy combinations. So when the study was designed as an investigator initiated clinical trial, the idea was really to capture patients across different tumor types - so head and neck squamous cell carcinoma, malignant melanoma, ovarian cancer, triple negative breast cancer, and a kind of mixed histology solid tumor cohort, where we knew that there were some patients who were going to be immunotherapy responsive, where there was already approvals or evidence of single agent activity, and others where the responses were more anecdotal, to try and understand in a phase 2 clinical trial with kind of a deep dive, which patients benefited from treatment and which didn't. Dr. Rafeh Naqash: Interesting approach. Going to the results, Alberto, could you help us understand some of the important findings from these data? Because there's different sections of how you tried to look at the response rates, the survival, looking at the immune deconvolution, if you could explain that. Dr. Alberto Hernando-Calvo: So the first thing that we tried was to further confirm the external validation of this immune gene expression signature, VIGex in the INSPIRE asset. So what we observed at VIGex-Hot, the category defined by VIGex-Hot tumor microenvironment, was associated with better progression free survival. After including that in a multivariable analysis adjusted by other biomarkers such as TMB, PDL-1 or tumor type, this was also confirmed for overall survival. So then the next step was to really try to hypothesize if the addition of ctDNA dynamics, taking into consideration the ctDNA quantification at baseline as compared to cycle three, if those dynamics could further improve the predictive performance of VIGex categories taken in the baseline samples. What we did observe was that, for instance, VIGex-Hot tumors in baseline tumor samples that were having a ctDNA decrease, as I mentioned before on cycle three assessment as compared to baseline, were having both better progression free survival and better prognosis overall. Another important finding was the evaluation of response rate across tumor types considering both biomarkers. I would say the most important finding is that when we were considering a cold tumor microenvironment in baseline samples before pembrolizumab initiation plus an increase in ctDNA values, what we observed is that those patients were having a 0% response rate. So this may help as a future strategy either for intensification of immunotherapy regimens in a more individualized way or for an early stop to immunotherapy and try to avoid financial toxicities as well as toxicities for our patients. Dr. Rafeh Naqash: From the data that you showed, it seems that there was a strong correlation, as you sort of mentioned, between individuals that had ctDNA clearance and baseline immune pro-inflammatory signatures. So do you really need the transcriptome signature or could the ctDNA just serve as an easy quick surrogate? Because from a cost standpoint, doing whole transcriptome sequencing or more RNA sequencing or tissue standpoint, where tissue is often limited, can become a big issue. So do you think that validation of this may perhaps more revolve around using ctDNA as an easier metric or surrogate? Or am I overestimating the utility of ctDNA? Dr. Philippe Bedard: I think it's a really good question. In our data set which was relatively small, there were 10 patients who had ctDNA clearance, meaning ctDNA that was positive at baseline was not detected. And so 9 out of those 10 patients, as you alluded to, were VIGex-Hot. So the question is a good one, could you do the same with just ctDNA clearance alone, particularly in identifying these patients who really do well, who have long term disease control on immunotherapy? I think it's a tough question to answer because the field is also changing in terms of sensitivity of detection of ctDNA tests. So we know now that there are newer generations of tests which can detect even at logs down in terms of allele variants in the circulation. So I think we need more data to address the question. I think it is important as to what is the best test, what is the endpoint that we should be using from a drug development point of view in terms of really trying to push and understand which treatment regimens are the most effective and have early readouts in terms of activity. Because we all recognize in the clinic that radiographic response doesn't tell the whole story, especially early radiographic assessments using RECIST or other criteria that we apply in clinical trials. Dr. Rafeh Naqash: From a clinical trial standpoint, we often talk about validation of these studies. You may have heard of other tests where, for example, the NCI iMatch, which is incorporating transcriptome sequencing based approach to stratify patients as an integral biomarker for treatment stratification. Is that something that you guys are thinking of using, this approach where individuals who are signature highly inflamed perhaps get lesser therapies or there's a de-intensification of some sort similar to what people are trying to do with ctDNA-based approaches? Dr. Philippe Bedard: I think that's a great question. I think it makes a lot of sense. And certainly, with the new wave antibody drug conjugates in terms of identifying patients who have expression of targets for antibody drug conjugates, that's very attractive as an approach because we don't necessarily have IHC markers for all of the different targets of antibody drug conjugates. We don't necessarily have IHC markers to completely understand different contributions to the tumor microenvironment and whether or not tumors are inflamed. But it's also a challenging approach too because RNA-seq currently is not a routine clinical test. Sometimes there are issues, particularly in patients who have stored specimens that are formalin-fixed and paraffin-embedded in terms of the quality of the RNA for RNA sequencing. And it's not always feasible to get pre-treatment biopsies and turn them around in an approach. So I think it is an attractive approach for clinical trials, but it's a hypothesis that needs to be tested. It's not something that is ready for clinical prime time today in 2024. Dr. Rafeh Naqash: One of the other interesting observations that I came across in your manuscript was that tumor mutational burden, interestingly, did not correlate with signature high tumors. What is the explanation for that? Because generally you would expect a TMB high to perhaps also have an immune gene high signature. Could it have something to do with the tumor types because there was a heterogeneous mixture of tumor type? Or I'm not sure. What else could you possibly think of that you didn't see those correlations or just sample size limitations? Dr. Alberto Hernando-Calvo: Yes. So our findings are consistent with prior data suggesting for instance T cell inflamed gene expression profile was also not correlated with tumor mutational burden and both biomarkers in a prior publication. So to have additive predictive performance for identifying patients most likely to benefit from anti PD-1 regimen, so we somehow were expecting this observation, the fact that both biomarkers are not very correlated. Dr. Rafeh Naqash: So given the proof of concept findings from your study, Phil, what is the next interesting step that you guys are thinking of to expand this? Would you think that a nivolumab-ipilimumab treated cohort would have similar findings? Or is this a treatment specific single agent immunotherapy specific correlation that you found versus something else that you may find in a nivo-ipi cohort or a doublet immune checkpoint cohort?  Dr. Philippe Bedard: The findings are really hypothesis generating. They require additional validation. And you're quite right, there may be nuances in terms of specific tumor types, combinations with other immunotherapy or combinations with chemotherapy or other agents. So I think it would be great if there are other data sets that are collecting this type of information that have ctDNA dynamics and also have transcriptome and potentially exome or genome analysis to look at these types of questions because the field is moving quickly and we really need more data sets in order to understand some of the nuances and greater numbers to validate the signals that we see. Dr. Rafeh Naqash: And one thing, as you said, the field is definitely moving very quickly. I was meeting with a company an hour back and they have an imaging-based approach using fresh tissue to look at pharmacodynamic biomarkers. And I used to work in the NCI with a group that was very interested and they developed an immuno-oncology pharmacodynamic panel that has been used and published in a few clinical trials where they did phosphorylation status. So the final theme that comes out of most of these research based studies that are being done is that one size does not fit all. But the question that comes to my mind is how many things do you necessarily need to combine to get to a predictive biomarker that is useful, that is patient centric, and that perhaps is able to identify the right therapy for the right patient. What is your take on that, Phil?  Dr. Philippe Bedard: Yeah, that's a great question too. The challenge is it depends on the context in terms of what degree of positive predictive value do you need as well as the negative predictive value to drive clinical decisions. So I think in certain situations where you don't have other approved treatment options and with a therapy that is potentially low toxicity and low financial toxicity, then I think the bar is very high in terms of being able to really confidently identify that patients aren't going to benefit. I think the nuance and the challenge becomes when you move into earlier lines of therapy, or when you talk about combinations of agents, or trying to understand within the context of other available options, particularly with treatments that have significant side effect profiles as well as financial risks, then it becomes a much more nuanced question and you really need comparative studies to understand how it fits versus the existing treatment paradigm. So I'm not really answering your question with a specific number because I think it's hard to give you a number. Some of that we also need input from patients in terms of what kind of level of validation do you need and what kind of level of discrimination do you need in order to drive decisions that are meaningful for them. Dr. Rafeh Naqash: Definitely early days, as you pointed out. More and more work in this field will hopefully lead us in the direction that we all want to go in.  Now, going to a different aspect of this podcast, which is trying to understand the trajectories for both of you, Phil and Alberto. And as you mentioned, this project seemed to have started in 2015. So I'm guessing there's a history there between Princess Margaret and Vall d'Hebron. Could you highlight that a little bit? And then perhaps, Alberto, after that you could tell us a little bit about your career when you worked at Princess Margaret as a fellow and then now back at Vall d'Hebron. Phil, you as well. Dr. Philippe Bedard: So absolutely. We have a long history of collaborating with Vall d'Hebron in Barcelona. It's really a great cancer institution with a lot of like minded individuals. We have a formal partnership and we have a lot of informal links in terms of scientists and clinicians who we work with and who we collaborate with on early phase clinical trials, as well as through different investigator networks and other translational projects. So this was really how this collaboration came about and we were fortunate to have Alberto, who came to work with us for two years and brought this great idea of looking at this signature they had developed at Vall d'Hebron in their phase one group and applying it to a data set that we had through the INSPIRE clinical trial.  Dr. Rafeh Naqash: Sounds like a very successful academia-academic collaboration, which is very nice to see. So, Alberto, could you tell us a little bit about your career trajectory and how you ended up at Princess Margaret and then back at Vall d'Hebron and what you do currently? Dr. Alberto Hernando-Calvo: Yes. So I did my oncology residency at Vall d'Hebron in Barcelona, Spain. Then I decided to further specialize in early drug development as well as head and neck cancer oncology. So I decided to pursue a clinical research fellowship under the supervision of Phil Bedard, among others. And so we decided to further validate the signature that we had developed both in the cancer genomic lab at Vall d'Hebron Institute of Oncology and the phase one unit at Vall d'Hebron, and apply the signature that have been originally tested in patients receiving anti PD-1 or anti PDL-1 combinations in early phase clinical trials. In the phase 2 clinical trial of INSPIRE, where we also had ctDNA dynamics and allowed us to test both biomarkers and see that additive predictive power when we were using both. That was one of my research topics under the mentorship of Dr. Bedard and my fellowship at Princess Margaret. And this was one of the manuscripts describing all the findings of this collaboration between Vall d'Hebron and Princess Margaret Cancer Center. Dr. Rafeh Naqash: And then, Phil, if you could highlight some of the things that you've done over the course of your career and perhaps some advice for early career junior investigators and trainees.  Dr. Philippe Bedard: I finished my oncology, medical oncology training at the University of Toronto in 2008. And then I did a breast cancer fellowship in Brussels at Breast International Group. At the time, I was really intrigued because it was really kind of the early days of microarray and RNA signatures in terms of expressing signatures were being used as part of a clinical trial that BIG was running called the MINDACT Study. And so when I finished my fellowship, I came back to Princess Margaret, started on staff. I've been here now for 15 years. I was fortunate to work with the phase 1 group and kind of my career has sort of morphed in terms of early drug development as well as genomics. I've been involved with the American Association for Cancer Research project GENIE, where I'm the current chair. This is really an international data sharing project with panel based sequencing, which both Princess Margaret and Vall d'Hebron have contributed to. And I've been fortunate to work with a number of really talented early career investigators like Alberto, who spend time with us in our drug development program and launched transitional research projects that leverage some existing data sets at their own institutions and also bring together with different research groups at our institution to lead to publications like this one. Dr. Rafeh Naqash: Thank you so much. This was very exciting. Phil and Albert, thanks for joining us today and thank you for allowing us to discuss your interesting manuscript and hopefully we'll see more of this biomarker work from you guys in the near future, perhaps published in JCO Precision Oncology.   And 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 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 week's Dads with Daughters podcast, we welcomed Katie Koestner, an influential activist and the executive director of the Take Back the Night Foundation, who shared powerful insights on teaching daughters about consent, autonomy, and resilience. Here are some key takeaways from their enlightening conversation. Understanding Consent and Autonomy Katie Koestner underscores the critical importance of educating daughters about consent and bodily autonomy. Consent is not a one-time agreement that cannot be retracted; it can be revoked at any moment. Katie emphasizes teaching daughters the difference between regret and rape, highlighting that a lack of initial resistance does not imply consent. This understanding is vital for fostering an environment where daughters feel empowered to assert their rights and boundaries. Healing from Trauma: A Collective Journey Healing from trauma is an arduous yet rewarding journey that necessitates patience and collective support. Katie reflects on her own experiences, noting that regaining power and control over one's life is a long-term commitment. It's essential for parents, especially fathers, to support their daughters through this process without taking away their agency. Fathers should help their daughters navigate decisions collaboratively, emphasizing that the journey and growth are more important than immediate outcomes. Mentorship and Community Involvement Community involvement and mentorship programs like Take Back the Night are instrumental in fostering resilience and support networks for young women. Katie encourages fathers to guide their daughters in engaging with empowering communities that can offer strength and solidarity. Participating in such programs helps build a sense of belonging and mutual support, which are critical for personal empowerment. Fostering Equal and Respectful Relationships To raise daughters who thrive in healthy, respectful relationships, fathers need to challenge archaic notions of women needing to be "taken care of." Katie advocates for teaching daughters the value of equality and collaboration within relationships. It's crucial for fathers to set an example by treating women with respect and equality in their own lives, reflecting these values in everyday interactions. Encourage daughters to seek partners who value collaboration, mutual respect, and independence rather than falling into roles dictated by outdated stereotypes. Practical Tools for Empowerment Katie offers practical advice for fathers wanting to empower their daughters. She suggests affirming their worth based on their talents, energy, and intellect, rather than appearance. Role-playing challenging scenarios can also help daughters prepare for difficult situations and build the confidence to handle them independently. Katie's conversation with Dr. Lewis reiterates the significance of dads actively contributing to their daughter's self-respect and ability to navigate the world confidently. Take Back the Night and Advocacy Katie remains a staunch advocate against sexual assault through her work with the Take Back the Night Foundation, which organizes events to raise awareness and support survivors. She encourages community involvement in various forms, such as bike races, walks, and vigils, to promote solidarity and resilience. Fathers can support this cause by participating with their daughters, fostering a shared commitment to ending sexual violence. In conclusion, the episode with Katie Koestner on the "Dads with Daughters" podcast provides valuable insights into raising empowered, resilient daughters. Through understanding consent, supporting the healing process, fostering respectful relationships, and active community involvement, fathers can profoundly impact their daughters' lives, guiding them toward independence and confidence. TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:16]: Welcome back to the Dads with Daughters podcast where we bring you guests to be active participants in your daughters' lives, raising them to be strong, independent women. Really excited to have you back again this week. And, you know, every week, I love being able to sit down, talk to you, and work with you as you're walking through this journey that you're on to be the best dad that you want to be, and working with your daughters to be those strong, independent women that you want them to be as well. That's why every week we have this opportunity to be able to sit down, talk, and to be able to learn and grow from each other, but also from the people that come on to our show. And it is really important that we're open to learning and growing and being able to truly hear what people have to say and to be able to take that in, internalize it, and turn it into something tangible that we can then use to be those dads that we want to be. And that's why every week I love being able to bring you different guests, different people with different experiences that can help you on this journey. And today, we've got another great guest with us. Katie Kessler is with us today. Dr. Christopher Lewis [00:01:22]: And Katie is a activist on sexual assault. She has worked for many years in the Take Back the Night Foundation. She is the current director of the Take Back the Night Foundation. She has a a story that we all should be here to be able to see what we can do to be able to assist our own daughters in having healthy relationships, but also to be safe in their lives as they get older. And I'm really excited to be able to have her here and to be able to have her share her story and also to provide you with some some things to think about as we're moving forward in our own parenting journey. Katie, thanks so much for being here today. Katie Koestner [00:02:07]: Absolutely. Chris, thank you for having me. Dr. Christopher Lewis [00:02:09]: It is my pleasure having you here today. I'm really excited to be able to share your story because it's not an easy story. And definitely, it's not I'm sure it's not been an easy journey as you have become the advocate that you've become in sexual assault. And I I know that not everyone has heard your name before and not everyone knows that story, but only you can tell that story in your way. Can you tell tell me a little bit more? Can you share your story with us and what led you to being the activist that you are today on sexual assault? Katie Koestner [00:02:43]: Absolutely. I am delighted to do so. So I think for all the dads out there, importantly, I am the daughter of an FBI agent and a homemaking mom. I grew up outside of Atlanta, Georgia, and then my dad was transferred to Harrisburg, Pennsylvania when I was in middle school, and I had a younger sister. I was pretty darn ambitious in every way, and, loved, I would say, everything from softball and swimming and field hockey to clarinet and trying to miss none on the SAT. I won a scholarship and lived in Japan when I was 16 on to 17 in high school. I was adventurous in every sort of the word. I decided to go up to college and went to the College William and Mary in Virginia as I double majored in Japanese and chemistry. Katie Koestner [00:03:34]: And the orientation was a whirlwind whirlwind experience, and I met a very handsome he could speak 3 languages, wanted to be a brain surgeon, played a great game of soccer, incredible, potential prince charming and well beyond what I had encountered in my life so far and quickly, you know, went out and hung out with him. And he asked me out to dinner probably the 3rd weekend and to the fanciest, most expensive French restaurant in town. And any of you who don't know my story, I'm not gonna share all of it here because it's on TED Talks, and I've only lectured at 5,000 schools, and I'm sure there's clips here and there. I've been on open Good Morning, American, CNN, NBC News, lectured in front of a quarter of a 1000000 people on the mall in DC, at the United Nations, at the Pentagon, just a few places along the way. But the end of the story is I simply trusted this guy. He paid for a very expensive dinner, and I thought he would respect my being a virgin and waiting till I was married. I wasn't drunk at dinner nor that night. And I simply told this guy no. Katie Koestner [00:04:39]: And for historic purposes, I'm sure I am older than many of the dads, who are listening. I might be younger than a few, but I was 18, and this was 1990. And I am the first woman in history to speak out nationally and publicly as the victim of date rape and appeared on the cover of Time Magazine at age 18. So I I stopped there just for a second because I think any dad listening is wondering now, when I already alluded to the fact my dad was an FBI agent, whether this, perpetrator was going to live to see another day when I knew exactly where he lived and could talk tell my dad. But, unfortunately, back then, my dad said I shouldn't have had the boy to my room and it wouldn't have happened. And while I think he probably had mixed emotions, and I don't wanna oversimplify, I do want to say that he was very traditional and very protective and very conservative, which means in high school, if a boy came to get me, he would probably fingerprint the guy's the front doorknob. He would wear his arsenal strapped on the outside as he answered the door. He would usher the potential boyfriend to the family room with the dead animals hanging on the wall and then motion to the back of the house where the targets for bows and arrows were set up. Katie Koestner [00:05:59]: He was easily intimidating to most guys. So before I go on, I I would say that my dad's never heard me speak in all my life, which is hard, and it's one of my motivations for coming on your show, Chris, because I have two main themes that I would get across, and then we can delve into the details. But I'm gonna start with the end first because this is way too important to me. My father told me what to do in regard to boys. He was very protective, and I never I never had a bad boyfriend in high school. Maybe that's because my dad was looming in the backdrop at all times, But I will also say to all the dads, protecting your daughter does not serve her. She's gonna have to do it herself at some point. And if not in high school, then when? So if she can learn how to fend for herself and navigate situations on her own, you are gonna have a much stronger, resilient, confident daughter who will be able to suss out when things are not safe by herself and calling you for help is not what you want to have happen. Katie Koestner [00:07:11]: You want her to navigate the hard situation, to come home that night or next morning at breakfast, and to say, dad, I did it all by myself. Sensed this one comment he made. I was around his friends who were making fun of women, and I knew better that this was not what I wanted, and I'm deserving of more. Do you want her to say that when what I wanted, and I'm deserving of more. You want her to say that when she's 14, when she's 16, and then you'll know when she goes off into the world, she's gonna do it better on her own because she had you to fall back on if she had to. But I would send her out on every date saying, you've got this. You deserve respect. It's not about your appearance. Katie Koestner [00:07:58]: It's about your amazing talent, your energy, your grace, and your brilliance. If you compliment her just on her appearance, you're gonna teach a frail daughter. I don't care how pretty she is, but you've got to compliment her on something other than that. So I start with, dads, don't protect your daughters. Let them teach themselves how to protect themselves. And the second thing I would say is be mindful of how you talk about women at all times. Be mindful of what you watch, what screens you're on, how you do or don't comment on women in movies, women in television, women in the media, women in politics, women in your work workforce. What do you say about women that's the same or different from men? And the more you treat all genders the same in terms of your analysis and your accolades or your criticisms, the better off your daughter is gonna learn how to navigate the world through equity and respect. Katie Koestner [00:08:57]: And then lastly, even if you're separated from the birth mother of your daughter, even if she is the worst person you've ever met, God forbid, always hold your hate inside and treat everyone even when they're wrongfully treating you, even if they're a train wreck of a human, it's really important that you teach your daughter that denigration is always wrong even when somebody else is wrong. So sorry that was a mouthful, Chris, but, like, I wanted to get those things out on the table and get dads really thinking about them because those two important things are probably the most helpful I can be. And I I would also footnote that I do have children now of my own. I have 16 year old twins. They're not girls. They're boys. And so I I'm on the flip side of your your equation. I'm a mom of boys, not a dad of a daughter, but I think we could talk about that later on is, like, how do you parent all your kids and how when your daughters are out on dates, if they if they actually like boys, who knows? What does that look like? Because I'm raising my sons. Katie Koestner [00:10:02]: I think they're both into girls, maybe not quite so much yet, but I I think that's the track they're on. I'm not too judgy. People are people, but I definitely want them to be somebody's best date and best memory even if they're not in men. I want them to be good, humble, respectful young men, and that's what you should be asking your daughters to look for if they're into men into boys. So and don't look me up if your daughter wants a date. Like, my boys are not once, like, ready for, like, full time studying and the other one's too much on his games to be even intriguing to a girl yet. So don't look me up for dates for your daughter. Dr. Christopher Lewis [00:10:40]: I love what you shared right there. And I think and I have to say, I'm sorry that you had that experience with your own father and but I appreciate what you had to say and the advice that you gave to fathers because I think it is so important for us as men and as fathers to be able to support our daughters in many different ways. And you talked about the fact that for you, one of the the first things that you mentioned was to treat your daughter to fend for herself, to be able to navigate situations by herself. I want you to think back to your own father and what could he have done for you that would have allowed you or made you feel that he was giving you the ability to fend for yourself? And what can other dads do tangibly to be able to start on that path with their own daughters? Katie Koestner [00:11:29]: Yeah. Fantastic question, Chris. And this is called, I would say, one of those conversations of courage. And not every human is wired to have this kind of conversation. And, I mean, I'm gonna be honest. A lot of people aren't comfortable with their own sexualities, their own relationships, and and men and women both. And I'll footnote it with this. If you're a dad and wants to have what I'm about to describe with your daughter, And you're like, oh, crap. Katie Koestner [00:11:55]: I totally can't do that. I don't have that vocabulary. I couldn't come up with that sentence structure. This makes me feel awkward. I I could look I'd be, like, so nervous. Like, that's totally okay. Not everybody has to be you know, not everyone's a brain surgeon. Not everyone's a psychologist. Katie Koestner [00:12:10]: Not everyone's into like, you everybody has different skill sets. What I want to have happen right now is for the dads listening to hear me model it and then say, if I don't think I can say this, I should at least tell my daughter. There's a few things I'm really awkward at saying that I want you to hear and then listen to this podcast. Push play, like, right here. Like, oh, I've listened to this woman, Katie, once, and she was trying to say it. I I can't do it the same way, but pretend it's my voice and I'm your dad. And, like, seriously, I don't I don't care. You it takes a team of, like, 8 or 9 people to raise a a great kid, and you have to have a lot of role models and a lot and all that matters to me at the end of the day is is intent and try. Katie Koestner [00:12:54]: I intend to do this. I tried to do this. I might not be great at it. People will see your intent and that you tried. So here's kind of what I would say. You said, how could my dad have done it? And it's very simple. You'd you say, like, she's really interested in a guy or somebody, a date, a prospect. She's going out to a party. Katie Koestner [00:13:11]: She's going to her first homecoming. She's going to the think of any number of potential social situations. The best thing you can say is, darling, sweetie, whatever you say. Jenny, Susie, you know, Aloysius, whatever her name is. You say, I know tonight's really important. I don't know how many of these kind of social things you've done, but what's really important to me is that you know you are that good. You know you deserve respect. You know what your morals, your values are. Katie Koestner [00:13:40]: You know what you want to to have happen tonight. Keep that in mind throughout the whole time. You wanna walk away from tonight feeling positive, respected. You wanna come home and feel like tomorrow's gonna be a great day. And if someone treats you at all with disrespect, you know that you don't have to take it. You don't have to stay in that environment. There's never an okay reason where someone should say anything that's degrading. No one should touch you in a way that makes you uncomfortable, and you can navigate a way out. Katie Koestner [00:14:12]: If you want to, we can role play some of the ways you could do that tonight. If you think you're all set, I'm here a phone call away, a text away if you need me. That's all. You just just remind her she's worth it. Put her eye on the prize, which is, like, at the end of the night, she wants to come home safe, respected, and tomorrow is gonna be a great day. And that's it. You don't have to go into the nitty gritty. You don't have to say, like, what if he tries to like, girls might feel awkward about that. Katie Koestner [00:14:40]: That could be a different class. Like, if somebody tried to touch you, how are you gonna if she wants to go there. But if you're just on square one, that's all you have to say. It's like, you've got this. Not like go, oh, you look so pretty, sweetie. You don't need don't say her dress is great, her skirt's cute, her hair looks great. That's fine, But, really, more important than how she looks is being being confident in how she should be treated all all night or all day. Like, whatever the event is, focus more on how she should feel and end up being respected. Katie Koestner [00:15:12]: Not like I mean, do logistics. How's she gonna get home? Who's driving? What happens? You could do some logistics. But if you just constantly say you deserve respect, you're amazing, you're talented, how do you want this night to end? Just focus on the the finish line all the time. I mean, what do athletes do? What it what's anyone who wants to a date is nothing more than an event where you wanna succeed. And succeed is, like, be safe and not be assaulted and have fun. Dr. Christopher Lewis [00:15:38]: Now one of the things you talked about in your story, you talked at the beginning that you met the gentleman at college, kind of the prince charming effect in many different ways. And then you talked about the importance of really as you're parenting and as you're working, not in in our situation here, in my situation, working with my daughters to identify and try to figure out what to look for in a relationship, whether it be with a man, with a woman, whatever it might be. I guess as you think back to your experiences and the experiences of others that you've spoken to on your podcast, Dear Katie, survivor stories or in your experience in speaking in so many different places. What advice would you give to fathers that are listening that could help them with their daughters to be able to navigate those relationships and help them to provide them with the tools that they should be looking for in those healthy relationships. Katie Koestner [00:16:41]: A healthy relationship, you're gonna hear a lot of working together, collaboration. It's not me, me, me, me. The partner or guy who's all about himself and constantly boasting or bragging, he's actually frail. Like, frail in his ego in that he might need to also eventually use his partner as part of his power play. And anyone who simply talks about themselves, their achievements, it's fine to be a high achiever. That's great. It's fine to be talented and smart, but it's really important to find a partner who's also equally interested in having a partner who is also talented, also brilliant, also smart, and wants to, like, do things collaboratively, not for. You know, old school men are like, I'll do this for you. Katie Koestner [00:17:30]: I'll take care of you. That language is dead. Nobody should be taken care of anymore. We're not in the dark ages. So I think the woman today needs to dad to say, you've got this on your own, and the best thing you can hope for is a collaborator, not a take care of her because no one's gonna be able to take care of anyone else unless you're being purchased, essentially. Being taken care of means you have less power, less equality, less confidence. No one needs to be taken care of. I think that this is not to say, and I wanna nuance this, you can have 2 totally different lanes. Katie Koestner [00:18:08]: And I'll even go so far as to say it's fine if one is a full time stay at home parent, and all they want to be is a, maybe, full time mom. I wanna have 5 kids. I wanna bake cookies. I wanna clean the house. I wanna be the PTA. I wanna do all I wanna volunteer. That's all fine as long as it's a pure choice. So, I mean, the gender roles, who cares? But the idea is, is there respect and valuation that's equitable between the partners? And that's a lot that's thinking way ahead. Katie Koestner [00:18:40]: But at the root of a relationship, when you start out, you can get your daughter thinking about how how does this partner value what I do? How does he or they see what I do? And if she's being taught and trained that she needs someone to be taking care of her, that's gonna only cripple her long term safety and success. Dr. Christopher Lewis [00:19:02]: I appreciate that as well because I think you're right. I mean, I know in my own situation with my own daughters, I don't want them to feel crippled by to their success as you just mentioned. I want them to be able to have those healthy relationships. And Katie Koestner [00:19:15]: Yeah. I think what I'd like to say, Chris, is it's gloriously amazing to be the power couple. Seriously, who wouldn't want that? You see you see a few that are still, like, kept wise and, you know, people kind of pity them now. Nobody's like, oh, what a glorious, fabulous relationship you have because all you do is dress up like a Barbie doll, hence the movie. But I think it's an age of glorious and we went through some individual like, you might go back. We're so old, Chris. Like, the eighties, you know, we had all the, like, me, me, me's. Then we had you know, the decades are interesting when we look back at them, but I think we're we're hopefully going into an age of this amazing it's the combination of individuality that blends together into cooperation to build something even more beautiful. Katie Koestner [00:20:08]: And I do think, you know, partnerships and relationships can be that good. It's really there's no such thing as a renaissance person anymore. Like, it's impossible. We have micro slices of everything in the world. So the best thing we can hope for is 2 really dedicated, kind, amazing, committed people who say, like, things are gonna get hard. That's I actually, that brings me to a really good point. Fights are good. Disagreements because you know why? The moment she comes your daughter comes home and is like, oh my god. Katie Koestner [00:20:39]: He made me so mad. You that's good. That's like, okay. Well, how did how did you resolve it? Because if you can't work together and not that's the tell. That's like the next level tell. If you have to think about the first date tells, like, where he makes some random joke or he can't pay look you in the eye if he's checking his phone every second. If he's asking you who your follow these are warning signs. Is he gonna say, why are you following him? What do you see? Like, jealousy is a really bad one. Katie Koestner [00:21:08]: Telling, like, why you why you not not allowing your daughter to have other male friends. That's a big red flag. Like, if a guy goes out with you and I mean, hello. It's it's 2024. Like, if you can't have male friends I remember I was in the chess club in 6th grade, and I was, like, the only girl. So I only hung out with boys, and I was not dating the entire chess club. Let me just tell you. No. Katie Koestner [00:21:34]: It was not like that. I was just like, these are the cool, smart guys. Like, I know. And luckily, back then, I had male friends, but I think you've gotta have a male partner who's good. You can talk to a guy and not be jealous. Like, even if he's cuter than you. Even if he's better at soccer than you. Like, who cares? Like, a secure guy is what you want. Katie Koestner [00:21:56]: He's not constantly jealous because he's ultimately gonna be manipulative and and doing power plays. That I would say that's another one. I'm thinking small things. I don't care about, like, send you flowers and open the door. Who cares? Sometimes people get hung up on, like, oh my god. I can't see the guy who holds the door. I'm like, give it up. Like, he's just trying to be nice. Katie Koestner [00:22:16]: Hold the door for him. If he sends you flowers, send him flowers. I think you break all the rules. And if he spies into silly stuff like guys can't get flowers, what's wrong with you? Again, it's 2024. I mean, maybe you don't wanna paint your nails blue as a guy, but that's fine. But if they buy into too many rigid stereotypes, there's going to be a problem down the road. And I think building in that, like, wow, creativity is helpful because later in life, the more open minded and creative someone is by the time they get to our age, Chris, you bet they're gonna get really dry and boring if they don't have a creative open mind. You wanna see all of those awesome traits. Katie Koestner [00:22:56]: I guess I last thing is do pay attention. I hate to say this, but many rapists, we didn't talk about this, many rapists themselves were also victimized. So do pay attention. No. It's a little bit let's say a few stats. Like, 1 in 4 women or girls is raped sexually assaulted in her lifetime. About 1 in 6 to 1 in 8 men the same. Now the difference is the 1 in 6 to 8 men often go on to become perpetrators. Katie Koestner [00:23:22]: And the 1 in 4 women, a lot of them go on to be victimized again because once you've had it happen once, there's such a huge blow to your confidence and ego as a woman. Many women turn that against themselves, their shame and blame, and many men turn it outward as anger. So a young man's own experience with relationships and and or abuse is really important to find. I mean, you don't wanna, like, quiz him on the first date and give him an interview, but you do wanna find out and see how do they if they have a mother, how do they treat their mother? If they have a father, how do they treat their father? How do they do they fight constantly? Is there a lot of tension? I hate to say it. It's not what they what do your parents look like? Because then I'll know how you look when you look old. Okay. That's fine. If the girl's like, I wanna see your dad. Katie Koestner [00:24:10]: Is he bald to know if he'll be bald? No offense taken. But, like, I think that's so not important. I mean, it is more important to see how they interact, though, with their siblings and with their parents. That part's really important. Dr. Christopher Lewis [00:24:26]: You know, those numbers are really staggering. And, you know, when I think of 1 in 4 girls experiencing this type of trauma, I guess one question that I would ask of you is thinking about that stat, how can fathers support their daughters if they come to them and say, I've experienced this trauma? Katie Koestner [00:24:46]: Okay. Two best sentences ever. Ready? 1 is well, 3. 1st is, I'm so glad you trusted me enough to tell me. 2nd is, I'm so sorry this happened to you. And thirdly is, what can I do to help you right now? That's it. And then everything else you're gonna have to figure out as you go because everyone's gonna be different. The situation might be urgent. Katie Koestner [00:25:08]: It might be immediate danger. It might be and I'll just nutshell it this way. There's 3 things to think about all the time. First one and I'll do them in order of expiration date. If it's recent, medical attention is paramount. Medical attention also means collecting evidence. You have 3 to 5 days after a sexual assault or rape to get evidence collected. It's free. Katie Koestner [00:25:29]: It's done at usually a hospital rape crisis center. It can be held evidence can be held for up to 2 years. There's no pressing immediacy to to go forward with the district attorney. But if you don't get the evidence, it can't be used later. And that's important because what many of the dads thinking about right now, it may not make sense. 84% of sexual assaults involve someone the victim knows. Trust, likes, not a stranger off the street. So if you get your thinking evidence collected, well, we already know who it is. Katie Koestner [00:25:57]: Even microscopic patterns of bruising and tearing on the victim can prove what her body position was in, whether she was asleep, passed out, if she was up against a wall. Like, all of it now is so great and scientifically proven that can help sway a jury if there was ever a trial about the likelihood of consent. So medical, medical, medical. And then, of course, pregnancy, STIs, all potential and have them looked at immediately. And, obviously, we've got a shape shifting goings on about what to do about unwanted pregnancies, including through rape across the country. So you'll have to think about what state you're in and what your okay. So that's first. And second after medical is reporting options. Katie Koestner [00:26:39]: If it's within 8 years, most states will take a rape case for criminal prosecution. If a girl is a minor when this happens, it might even be longer. But mindfully, let's nuance this a little bit. Let's say she's 14 and her boyfriend's 17. That could be statutory rape in most states, even if it's her boyfriend. So if your daughter is 14 having sex with her 17 or 18 year old boyfriend, that technically could be rape in most every state in the country. I'm not sure you wanna prosecute her boyfriend if she really likes him, if you find out they had sex, but I'm just letting you know. If indeed it was an adult, let's say it was her 30 year old soccer coach, that's definitely gonna be sexual abuse of a minor, and the statute of limitations on that can be much longer. Katie Koestner [00:27:25]: It can be entirely a whole lifetime. So the age does matter and the state does matter for how long you have to criminally prosecute. Luckily, luckily, Take Back the Night, the foundation has started. The, the Take Back the Night predates me by a lot. It's over 50 years old as a movement around the world to end sexual violence and support survivors. But over 20 years ago, I corralled all the event holders and created the foundation. But we, about 4 years ago, also put together something called the sexual assaults victims legal support hotline. So that is so important. Katie Koestner [00:28:02]: It's 1567 shatter for any dad listening. That's free. It's confidential, and it puts you through to an attorney who's steeped in this kind of information who can go over your rights and options. I just put that out there in case someone's all of a sudden interested. But that that's criminal. Then you also we have 2 more systems of reporting of justice. So I think of them as the 3 c's. We have the criminal system, then secondly, we have the civil system. Katie Koestner [00:28:30]: Civil is where let's say your daughter was assaulted by the soccer coach at school. She could potentially sue the school. You you know, you all could because of sexual assault of a minor and failure to protect her and all kinds of things. A civil suit, you usually just have 2 years. Again, there's some exceptions. The third one, though, is the campus reporting system. If it's a college, you have as long as the perpetrators affiliated with the college, you can report it and have some sort of adjudication. If it was your high school or elementary school or middle school, same deal. Katie Koestner [00:29:05]: There's also a school campus system. So remember, criminal, civil, and campus are three areas where you can report. And that legal support hotline I just mentioned, 567 shatter, is a great option to learn about any and all. The third thing so we did first is medical attention. 2nd is reporting. The third thing to tell her is emotional or long term support and healing. There's no expiration date. Obviously, that can be done anytime. Katie Koestner [00:29:33]: There's no one size fits all. It could be their rabbi. It could be their priest. It could be a professional rape crisis counselor. It could be online BetterHelp. It could be there's a million different ways to get emotional support, but it takes more than one person to heal. Meaning, the victim by themselves almost always benefits from having someone else to talk to. And sometimes the parent needs also support and counseling. Katie Koestner [00:29:57]: You're a secondary trauma victim. You're trying to help your daughter, and it can feel exhausting. So don't hesitate to do good self care for you and your partner along the way or your other children. You know, it can be so devastating and frustrating, and the spin out can include everything from drug addiction, alcohol addiction, suicide, eating disorders, like metal, all kinds of depression, it can be really rough. Bodily trauma of a sexual nature is just really hard to process. Dr. Christopher Lewis [00:30:28]: One of the things that I guess from what you 2 were talking about is that education is important. And especially health and wellness education when it comes to our children's bodies and helping them to understand that. What would you say are some practical steps that fathers can take to educate their daughters about consent and what they should know for themselves as they go out into the world? Katie Koestner [00:30:53]: Well, some schools do a really good job of consent education. Many do not. But essentially, that was the whole if anyone researches back into my case, when I was raped at William and Mary, the entire country and William and Mary's policy had sexual assault and rape as only happening to women by definition because only women were property and rape was a crime of property. That's the history of it. You know, when you hear the phrase damaged goods, damaged goods basically meant a woman was no longer a virgin. She'd be more expensive to marry off, and that's where that phrase came from. And I was the one who came along at 30 3 years ago, Chris, and said, I'm not damaged goods. And if a man doesn't wanna marry me, I don't wanna marry him. Katie Koestner [00:31:37]: And why is rape the only crime where force is required? If I reached out and said, give me your money and you had your wallet in your hand and I just took it, I wouldn't have to you wouldn't have to say, well, she punched me to take it. If I took your wallet, I stole from you. Like, whether or not you, like, had a very nice gold watch on, you could be, you know, wearing expensive clothes. No one could say, oh, you must give away lots of money and be rich. Why would you miss your wallet? You were asking for it. But I go back to consent because I helped rewrite the law to say it should be simply the lack of consent, not the action of resistance. And dads, dads, dads, that's critical. Your daughter doesn't have to fight off her attacker, and she doesn't even have to say no even though that would be great, I'm sure, in your minds. Katie Koestner [00:32:26]: But if she freezes up and doesn't feel like she can do anything and just lays there, that's still not consent. So it's really important for you to validate. Like, don't rank how she responded. Like, if only you had been, like, superwoman and had out your gold braces and your golden whip and, like, your steel belt, you know, and gotten the guy. Like, who cares? It's over. It was still wrong. It's not, like, more wrong or less wrong. It's just wrong wrong. Katie Koestner [00:32:53]: So all rape is wrong wrong. There's not like, oh my gosh. I here's a fun story, Chris. In all the education I do, one time I was talking to some boys in high school, and one was like, but, you know, what if she leads me on? And I just get it's I'm I'm at the point in a return. And I said, oh my gosh. That's so that sounds so interesting. Like so let's just run this through. Like, imagine you're over at your girlfriend's house and you're making out on the sofa because her parents are gone out for the weekend or out of town, like, for dinner or something. Katie Koestner [00:33:22]: They're out out, and you 2 were just going at it, and you're at this point, you know, return. And then all of a sudden, at the back door, you hear the jingling of the keys. The parents are unexpectedly home. I said, young man, I know exactly what you would do. You'd holler out, like, mister and missus Smith, you think you could just wait outside for a couple of minutes? I'm almost done with your daughter, and it's the point of no return for me, and I just can't stop right now. You know, like, the absurdity. Right? Like, any there's no such thing. We're not animals. Katie Koestner [00:33:50]: We can totally stop. Even if it's uncomfortable, awkward, embarrassing, horrible, there's no such thing as we're not out of our mind and body having sex. So I think it's really important to tell your daughter, like, if all of a sudden it's hurting, if it doesn't feel good, whatever her I don't know what the values of your dads are, but whatever they are, she should know. There's no point at which it's too late to say no. I say when someone said to me, Chris, once, they said, when is rape regret? And I said regret is when you change your mind afterwards. Rape is when you change your mind in the middle and they don't stop. If you change your mind after after and say, I shouldn't have done that, that's regret. It's not rape. Katie Koestner [00:34:31]: If you change your mind, 5 minutes in, if they keep going, it's still rape. So I think those are those are nuanced things for dads to hear, but I think if they can talk to their daughter, and that sounds like a way awkward conversation for most dads, but just put the podcast on again. This is sex ed consent ed 101. Dr. Christopher Lewis [00:34:49]: You know, the other thing you just talked about was the fact that healing takes time, and it takes effort. And it's it's, something that's going to be a multi year entire life situation. So talk to me about the process that you had to go through, but also that what you tell to other survivors in regards to what it looks like to regaining power, regaining your life, but also are there things that dads can do to be able to support their daughters on that journey? Katie Koestner [00:35:21]: I'll start with the last part of your question first. Things dads should not do is take away agency. Meaning, here's the difference and nuance there. Taking away agency, it means not doing everything for them or telling them what to do. Taking weight, that's taking away agency. Giving agency means let's make a list together and let's do the research. If you're up for it, help me do the research. If not, I'm the dad. Katie Koestner [00:35:47]: I I'll take this on. I'll make the whole list of options that I can find. Then I'll review them. Let's think about them together. The best thing a dad can do or anyone could do is start to collaborate and build more control and power and agency back into the victim. The more you here here's a good small point. If they really want to try if you wanna put the guy in jail, let let's say the traditional dad reaction, we need to put him in jail. You know what? The average rapist rapes 12 to 17 times before going to jail. Katie Koestner [00:36:19]: The conviction rape on sexual violence is the lowest of any crime. This is the tough reality. It's fine. So jail time is not likely. However, the entire process of seeking power and control and some sort of I tried is that in and of itself has to be honored. And so often, I think I hate to ever stereotype men, but men sometimes get caught up on the outcome instead of the process. Men sometimes wanna come up with the answer instead of talk it through. You know, that's a total stereotype. Katie Koestner [00:36:52]: Women are like, I just wanna talk to you about this. I don't need an answer, and I wanna get men better at like, I'm very outcome driven, Chris. Like, seriously, like, I'm just one on the SAT. I'm a math girl. I'm a science girl. I like the data. I like to crunch the numbers. I like to win. Katie Koestner [00:37:09]: I like to be successful. I like to speak in front of a quarter of a 1000000 people. You know, I'm very, very driven. So but I also like the process because what I did helped. So I'll go back now to the other part of your question. So dads should sit with the process. Don't take away the agency. Don't provide the outcome. Katie Koestner [00:37:27]: Don't get to the finish line. Let your daughter run the marathon herself. She's got to. However, what happened in my world was a little unique because there was no name for what happened to me. So I literally had to research everything old school before the Internet, go to the library, get some books, read law books at the law school at William and Mary. I did what I could because I was confident enough in every aspect of my life that I could do this. And I got there in high school and in middle school. Like, I had already felt like the one good thing I will say my parents did is they they're like, do everything. Katie Koestner [00:38:04]: They always said you're never good enough, but they were they were also like, do everything. They never limited what I could do except for going to MIT. I wanted to go to MIT. Sorry. Well, they said we don't have enough money for MIT, and there's not enough girls there. That's what my mom said. Anyway, that aside, I think what helped me so much was I learned and I taught and I sat in it and I did everything. I changed laws. Katie Koestner [00:38:27]: I tested on in Capitol Hill. If you read that Time Magazine, you'll see me testifying on Capitol Hill when I'm only 18 years old. I made a movie with HBO about my story. No one helped me. I just did it. I went to New York City to get that picture taken. I I I debated the vice president of my my college on Larry King Live when he was alive. I stunk at it. Katie Koestner [00:38:47]: I was a terrible debater. I went and I did and I flew and I tried and I talked to other survivors. I became a rape crisis counselor. I answered that hotline from 11 to 7 AM while I was in college. I immersed myself in the pain of myself and others by full immersion, and I won't say I deleted everything else. I'm very lucky. I still was getting a's and still going to classes and still am doing everything else. But I think that by burying things, we hurt more. Katie Koestner [00:39:17]: The wound does not heal with a patch. The wound heals when we put it in full sunlight and we we just go with it. And who cares? Like, that's a great scar. You got through it. You survived, and you went on. For a while, I wanna go back one thing. Your daughter might go through a phase. Why in the blank did this have to happen to me? Is there something wrong with me? And you've simply gotta tell her it happens to a lot of people. Katie Koestner [00:39:42]: It's not you. You're unfortunately, my dear, you're not special. It happens to 25% of women. So it's just you were one of those, but let's makes it had to happen for you. Let's why? Let's do something with this. Let's make it into something more. Let's make it part of who you are in a positive way. And and and I would and here's a way that I think about that. Katie Koestner [00:40:02]: If someone you care a lot about in your life dies, like your grandmother, your auntie, you don't say when are you gonna get over it. That pain, that horrible gap in your heart, no one says, when are you gonna stop missing your grandma? That's wrong. Big losses in life, you're like, how do you honor her? Big losses, we honor them if we're on the right path. We figure out what's glorious about that, about her, about that experience, and what goes forward. That's the way to to spin anything. And and and and even for the dads who fortunately, hopefully, don't have daughters in distress, start teaching her how to spin everything that's bad into positive as fast as possible. Get over it. It's not you. Katie Koestner [00:40:43]: It's them. How do I navigate a different path? If I don't like what I'm on, how do I change the lanes? That is resiliency. I'll say, like now I'll also say this for any dad who's still listening to me. Your daughter's I have a 14 year old intern on my team. She is magnificent. She helps with my podcast, and I mentor, if you have a daughter who wants to kick butt in the world, join the Take Back the Night team. We have volunteers across even all the way to Kenya. We have Benter who does our like, it's so cool and amazing. Katie Koestner [00:41:15]: We empower every single woman, and and we teach them business skills. And if your daughter can't like, how about flourishing with fabulous, like, international global women, young women? Like, we have amazing women. I would our 14 year old is the youngest volunteer, but my gosh, we have a team of, like, 50. They're so we put them on teams. Like, your daughter should be around, like, if she's on into sports. Like, what team is she on? Don't let her isolate. Don't let her find her heart just in one boy. Like, put her around amazing people who are gonna push her, help her thrive. Katie Koestner [00:41:57]: That's gonna make her really amazing. So I'm just plugging, like, I don't care if it's Take Back the Night. I do care if it's something. Just find some way to put around, not just singing. I know. Not pooh poohing singing. I can't sing at all. I can't do singing. Katie Koestner [00:42:15]: I can't do car wheels. But I I think, you know, it's putting around people who will push her in a positive way. Honor her spirit, push her enough to be ready to take criticism in a positive way. Like, all of the things you want. Right? Like, those are all great things. They're very idealistic. If you can't tell, I'm very positive that the glass is always almost full. Dr. Christopher Lewis [00:42:40]: Well, Katie, I just wanna say thank you for sharing your journey, but sharing all of this amazing insight today. If people wanna find out more about you, your story, your organization, where should they go to find out more? Katie Koestner [00:42:53]: Love, love that. First of all, believe it or not, I still go around the country and speak. I just got back from speaking in Nantucket. How fun was that? I took a ferry to my speech. That's the first time I could say that. But I think I love speaking, but I also have a team of speakers. So if you want more education in your community, that is either Google Katie Koestner, my name, or you can go right to campus outreach services, and that's education and awareness. There's tons of ideas there. Katie Koestner [00:43:23]: 2nd idea, take back the night. We are always eager to have more volunteers, more financial support. Go read about the hotline and coolness. You could even plan a take back the night event in your own community. We have a whole team who will help you. It's just a one day event of awareness. You could do a bike race. You can do a walk. Katie Koestner [00:43:42]: You can do a vigil. You can have it at your church. You can have it at your school. You can have it at your business, but an event is a way of honoring and bringing awareness. So I encourage everybody to do that as well. But thank you, Chris. This is fabulous. This is so much fun. Dr. Christopher Lewis [00:43:58]: Well, I truly appreciate you being here today. Thank you for all the work that you're doing to support so many across the globe, and I wish you all the best. Katie Koestner [00:44:06]: Absolutely. Take care. Dr. Christopher Lewis [00:44:08]: If you've enjoyed today's episode of the dads with daughters podcast, we invite you to check out the fatherhood insider. The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual, and most dads are figuring it out as they go along. And the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step roadmaps, and more, you will engage and learn with experts, but more importantly, dads like you. So check it out at fatheringtogether.org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with Daughters is a program of fathering together. Dr. Christopher Lewis [00:44:57]: We look forward to having you back for another great guest next week, all geared to helping you raise strong empowered daughters and be the best dad that you can be. Dr. Christopher Lewis [00:45:06]: We're all in the same boat, and it's full of tiny screaming passengers. We spend the time, We give the lessons. We make the meals. We buy them presents and bring your a game. Because those kids are growing fast. The time goes by just like a dynamite blast. Calling astronauts and firemen, carpenters, and muscle men Get out and be the world to them. Be the best dad you can be. Dr. Christopher Lewis [00:45:59]: Be the best dad you can be.

An Educational Journey Turned Parenting Mission Jen Lumanlan's shift from a sustainability consulting career to a focus on parenting wasn't incidental. After grappling with the challenges of raising her own daughter, she realized that academic research on child development could serve as a guiding light. This led her to pursue master's degrees in psychology and education, and subsequently, to the creation of her podcast and book. Her primary goal? To leverage her learnings to support other parents facing similar challenges. Challenging Conventional Discipline Understanding the Power Dynamics at Play At the heart of Jen's approach is the critique of conventional discipline methods such as timeouts and consequences. According to Jen, these methods often perpetuate harmful power dynamics. They emphasize a power-over relationship, where the authority figure (the parent) uses their power to correct or control the child. These traditional methods can breed resentment and a lack of genuine understanding. Exploring Alternative Strategies The Shift From Control to Collaboration So, what can parents do instead? Jen advocates for strategies that satisfy both the parent's and the child's needs, fostering a power-sharing relationship. For example, during conflict, she suggests addressing the situation outside of the moment of crisis. Proactive discussions about recurring issues like tooth brushing or bedtime can pave the way for more harmonious solutions. By understanding and meeting each other's needs, both parties can find agreeable strategies, reducing resistance and conflict. Identifying and Meeting Needs The Two-Way Street of Parenting Needs Parents often neglect their own needs in the face of their child's demands, but Jen emphasizes that both parent and child have valid needs. Strategies should aim to fulfill both. She introduces the concept of "cherry needs" — the most critical needs that recur for both parents and children. For instance, a child's need for autonomy can be met with choices that do not compromise the parent's essential needs, such as brushing teeth in a different room. Problem-Solving in Real-Time Navigating Tantrums and Meltdowns Tantrums and meltdowns are common challenges, and Jen offers peace and empathy as the best tools. Understanding the underlying needs that prompt such behaviors and addressing them proactively or with empathetic responses in the heat of the moment can defuse tension. Validating the child's feelings and needs even during a meltdown can lead to quicker resolutions and more trust. Shifting Dynamics with Teens It's Never Too Late to Transform Relationships Parents of older children might assume it's too late for change, but Jen underscores that it's never too late. Even with tweens and teens, shifting from a power-over to a power-sharing dynamic can salvage and improve the relationship. She proposes using phrases like “I'm worried that…” to express needs and concerns, fostering mutual respect and understanding. Healing From Our Own Childhood Breaking Cycles Through Self-Reflection Many of our parenting triggers stem from our own childhood experiences. By unpacking and healing these old traumas, parents can become more conscious and connected. This self-awareness prevents past negative patterns from repeating, helping parents respond more thoughtfully rather than reacting on impulse. Broader Societal Change Raising Children Who Challenge Injustice Jen believes that by fostering power-sharing relationships at home, we can equip children to challenge systemic injustices. When children learn to view all individuals' needs as equally important, they carry this perspective into broader societal contexts, questioning and challenging systems of domination and inequality. Jen Lumanlan's insights offer valuable guidance in our quest to raise empathetic, empowered children. By shifting from control to collaboration and addressing the deeper needs within our family dynamics, we not only nurture healthier relationships but also contribute to a more just world. Tune into this enlightening episode of Dads with Daughters for more practical wisdom on transformative parenting. Connect with Jen and deepen your understanding of parenting dynamics at Your Parenting Mojo. TRANSCRIPT Dr.Christopher Lewis [00:00:05]: Welcome to Dads with Daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:16]: Welcome back to the Dads with Daughters podcast where we bring you guests to be active participants in your daughters' lives, raising them to be strong, independent women. Really excited to have you back again this week. As always, every week, you and I are on a journey together. I love being on this journey with you where we have an opportunity to be able to learn together about what it takes to be that dad that we wanna be. And all of us wanna be that those engaged dads, those dads that are there for our kids. And it takes work. It takes time. It takes effort to be a quality parent, and it takes resources. Dr. Christopher Lewis [00:00:55]: And that's why this podcast exists. Every week, I love being able to bring you different guests, different people with different experiences that can bring different resources to you, different different opportunities for you to learn and grow. The the biggest thing is that you're open to learning. And that's what I hope for me for you every week when we're talking. This week, we got another great guest with us. Jen Loominlan is with us today. And Jen hosts the Your Parenting Mojo podcast, which was named the best research parenting podcast by Lifehacker. It's been downloaded over 3,000,000 times. Dr. Christopher Lewis [00:01:33]: After attending Berkeley and Yale and following a traditional career path in sustainability consulting, Jen found that parenting was her toughest challenge yet. She went back to school for a master's degree in psychology focused on child development and another in education and trained as a coactive coach to share what she learned with other parents. She's an author of the book Parenting Beyond Power, How to Use Connection and Collaboration to Transform Your Family and the world. And today, we're gonna be talking with her about her own experiences and these experiences with the book and some of the things that you can take out of this book to help you to be that parent that you wanna be. Jen, thanks so much for being here today.  Jen Lumanlan [00:02:16]: Thanks for having me. Dr. Christopher Lewis [00:02:16]: It is my pleasure. I mentioned the fact that you've got this book that you've put out into the world. As an author myself, I know how much time, effort, passion has to go into putting a book out into the world. And it is a lot of time and effort, and you have to have a passion for it to be able to get to that end point. So tell me the story. What what was it about? You know, I introduced you. You you had this career, but you said, you know what? I wanna go back and I want to do do more work on education, work with parents. But what made you decide that you wanted to put all this into a book that was gonna help others? What drew you to that final point? Jen Lumanlan I think I started the podcast because, you know, I had no idea how to parent. And I didn't have the most amazing parenting role models myself either, and so I realized I could look to academic research to help me understand how to go about raising my daughter. And so I kind of figured, you know, I I should get some education on this so that I can put some kind of guardrails around it and know I'm not missing anything huge, and that's what led to the master's degrees. And and then I was kinda thinking, well, it's kinda silly to do all this learning for myself and not share it. So I created the podcast to share that with other people. And then I over the course of of sort of exploring a lot of topics on the podcast that we have over 200 episodes now that are all research based. And I think, you know, it became really clear that I was hearing similar challenges from parents over and over again. And and they're kind of variations on the phrase, how do I get my child to Right? How do I get my kid to put their shoes on in the morning, to eat their breakfast, to stay at the dinner table, to get in the bath, to stay in bed at the end of the night? You know? And that's just the toddler set. Jen Lumanlan [00:03:59]: The challenges expand from there. So, what I realized was the the tools that I had learned from others and kind of adapted with putting my own spin on them were really helping parents to kind of address those challenges, those daily challenges on a day to day basis. And at the same time, they also help us to address some of the big challenges that we face out in the world that are related to kind of being in power over relationships. And it turns out that our kids learn a lot about power from our relationships with them and when we're using our power to get them to because it seems like that's the only thing we can do. Right? We just wanna get through the day. It's not we want to use our our power over our kids. We're just trying to get through the day. And we use our power because it seems like that's the only option we have because that's what was modeled for us when we were kids. Jen Lumanlan [00:04:50]: And if we can instead see how to be in a power sharing relationship with our kids, then our kids stop resisting us because you don't resist when your needs are met and when, you know, when you're not being sort of dominated by somebody else. And and also that will help us to address some of the social challenges we face that have their origins in these power based relationships. Dr. Christopher Lewis [00:05:11]: So let's talk a little bit about power because in your book, you do talk about the that that power dynamic, and you challenge conventional discipline methods like timeouts and consequences. And you suggest that they perpetuate harmful power dynamics like you just were mentioning. So what are some other alternative strategies that parents can use when they feel overwhelmed, or when they feel that their child's behavior is especially difficult? Jen Lumanlan [00:05:38]: So the I mean, firstly, the challenge with those conventional discipline methods. I mean, if you ever put a child in time out, right, do they come out of time out kind of contrite and ready to apologize for the thing that they did wrong and they never do it again? Right? No. They usually kinda resent being in time out. They come out of it kinda pissed at you, and they do it again. Right? They do the same thing over again. Same with consequences. We can we can withdraw a privilege of some kind. We can punish a child in some way, and we can call it a, quote, unquote, logical consequence because it seems like the punishment is sort of related to the thing they did wrong. Jen Lumanlan [00:06:12]: But, essentially, it is a punishment. It is us using our power to say your behavior is not acceptable to me. And until that changes, I'm going to withdraw this thing that you care about. Right? We are using our power to to make both of those things happen. And so what what I want to make sure that that your listeners understand is that I am not advocating that we parents suddenly say, okay. Whatever you want. Totally fine. Totally cool. Jen Lumanlan [00:06:32]: Right? I'm just here to exist to enable you to live your best life. No. What I'm saying is that both parent and child have needs. And the way that we use the word need in our culture is a little bit odd. Right? Like, I might say, I can't play with you right now. I need to make dinner. And needing to make dinner is not actually a need. That's a strategy that I'm using to meet my need for food, for nourishment. Jen Lumanlan [00:07:01]: Right? And there are a 100 other strategies we could use. I could toss a pizza in the oven. We could go out and get dinner. I could ask someone to bring us dinner. We could have cereal for dinner. So many different strategies we could use to meet that need. And so what I'm saying is that you, parents, are a whole person with needs, and you deserve to get those needs met. And your child is a whole person with needs, and your child deserves to get those needs met. Jen Lumanlan [00:07:26]: And the vast majority of the time, preferably if we're not dealing with it in the moment. Right? We're not we're not waiting in for this thing that our kid does over and over and over again, and we're not waiting for that to happen. Then, okay, needs? What what am I supposed to do? Right? Instead, we can actually address that outside of that difficult moment. We can say, hey. I noticed we've been having a hard time with tooth brushing lately. Can we have a chat about that? Because I'd really like for that to be different. I'd like for our evenings to be different. Would you like for our evenings to be different? Chances are the kid probably does. Jen Lumanlan [00:07:53]: Because if this is a big deal to you, then, you know, there have been time outs and all kinds of stress around toothbrushing. And then, okay, so we're we're trying to understand how each person is feeling. We're trying to understand what each person needs. And what the need is determines the strategy that we can use to help them meet the need. So I'm happy to dig further into that if you'd like, but I'm curious if you have any questions about that aspect. Dr. Christopher Lewis [00:08:14]: No. I'd love to delve a little bit deeper into needs because I know that in the book, you do talk about the importance of meeting both the parents and the child's needs, like you were talking about to reduce that conflict. So how can parents begin to identify and prioritize their own needs without feeling guilty or neglecting their children's? Jen Lumanlan [00:08:32]: So it's super common for the parents that I work with to say to me, before I started working with you, I didn't even know that I had needs. Because we didn't learn this when we were kids. Right? And so just to be clear on what I'm talking about related to needs, I'm talking about things like rest, like self care, like respect, which is not necessarily having everybody do everything you say. Right? It can be, like, holding someone in esteem and high regard. And we all want respect, and our kids want respect too. It's things like ease. And we just want parenting to be a little bit easier for collaboration, for harmony with our kids. Right? These are the kinds of things I'm talking about related to needs. Jen Lumanlan [00:09:10]: And so if we take tooth brushing as an example, right, could imagine if tooth brushing has been stressful because my kid has been resisting it. Let's say my kid is a toddler. My kid's actually 10 by now. But let's say it's a toddler, and I might think, okay. What is my need in this? Right? I might I might have been saying to my child, I need you to brush your teeth. That's not actually my need. My need is for protection of her health and safety. It is for a little bit of ease and collaboration and harmony in the evenings at the end of a long day. Jen Lumanlan [00:09:39]: And if you're wanting to, like, explore what needs are, there's a a list of needs in the back of of the book. And there's also a quiz that I offer at your parentingmojo.com, which allows you to go through it's your parentingmojo.comforward/ quiz, and you can answer some simple questions about your child's behavior and get to your child's most important needs that come up over and over and over again. And you may well find that some of those are coming up in tooth brushing. So if your child has what we call a cherry need, right, there's the cherry on top of the cupcake, which is the 3 to 5 needs that are coming up over and over and over again. For many toddlers, autonomy is right up there at the top. They want to be able to have some kind of say over something that feels important to them. Underneath that, we have the frosting needs, which is the next 3 to 5 most important. Underneath that is kind of all of the other needs. Jen Lumanlan [00:10:26]: And so we're always firstly looking at what are those cherry needs, and that quiz is gonna help you to understand what your child's cherry needs are. And so even if your child isn't speaking yet, right, if your child is too young to speak, if your child doesn't speak, if you've done this quiz, you can say, okay. What is it an autonomy? Is it possible the child wants to have some kind of say over what's happening here? How can I make that happen? Right? You're not giving the child necessarily the choice, do you want to brush teeth or not? But what kind of toothpaste do you wanna use? What kind of toothbrush do you wanna use? For us, oh my goodness. It it turned out to be I my daughter wanted to decide where we brushed. For a solid 6 months, we brushed in the living room. And so I might initially think, no. She should have brushed her teeth in the in the bathroom. That's where teeth are brushed. Jen Lumanlan [00:11:10]: Right? But if I can find the cognitive flexibility to say, alright. What are my needs? Her health and safety, peace, ease, harmony. Does brushing teeth in the living room meet my needs? Yes. It does. Does brushing teeth in the living room meet her need for autonomy? Yes. It does. Then is there a reason why we can't brush teeth in the living room? No. There is not. Jen Lumanlan [00:11:28]: And so that's what we did. And so the critical, critical piece here is that when it's a need for autonomy, right, it's not it's not the brushing teeth in the living room. It's some magical solution that will work for every child. If your child has a need for comfort, right, if you've been holding them down and forcing the toothbrush in their mouth, saying, let's brush in the living room is not gonna address that. And so we have to know what is the child's need, and then we find strategies to meet their need. And it feels good to have our needs met, and everybody wants to have it happen. And so that's how it helps us to get both of our needs met. Dr. Christopher Lewis [00:11:59]: So another thing that your books talk about, and really what you just kind of framed seems to fit in with it, is one of the key concepts you talk about is your problem solving approach, and it it basically what you just described. Are there other parts though of that approach that you could walk us through that would allow for someone to get a better sense of what the approach kind of how an adult would frame that approach, and also how a parent might then apply it to other challenges like tantrums or other situations like that. Jen Lumanlan [00:12:34]: What I want to have parents see is that very, very often, these are not isolated instances. When your child is having tantrums, chances are it's kind of about the same thing over and over and over again. And so that represents a huge opportunity because you don't have to wait for the next tooth brushing session to address this. You can address this beforehand while everybody's calm, everybody's rested, everybody's fed, nobody's at the end of their rope. Right? That's the time ideally we want to address this. And that allows us to have more of a conversation. And even if your kid isn't talking yet, kids sense the difference between, you're gonna brush your teeth because I said so, because because I want what's good for you, and you have to brush your teeth so you don't get cavities, and all the reasons that we give them. And, oh my gosh, I really wish that this could be easier for both of us. Jen Lumanlan [00:13:22]: I'm trying to figure out how do we meet both of our needs here. Right? Kids know the difference between those two things. And even if you can't fully understand the child's need, they are often willing to come towards you because you're trying. But I also wanna give you an example of, like, in the moment the kid is already melting down. And so I'm thinking of a parent that I coached a while ago whose child was having this meltdown, and it was coming up because the child and the parent were having 1 on 1 playtime in the afternoon, and it's coming time to go and pick the older child up from school. And so the kid has, like, a you know, the kid the the younger child who's at home with the parent is having a fallout on the floor, wailing, hitting, biting, all the rest of it meltdown that's happening. And the parent is trying to reason with the child. Right? Come on. Jen Lumanlan [00:14:06]: It's time to go. We do this every day. Why is this so hard? We already had playtime. Let's go. And if you've ever had a meltdown yourself with your partner, with anyone else who's in your life, if you imagine your partner coming back and saying, but I told you a 100 times, this is how we do it. We can sort of get a sense for what it might be like to receive that from our parent. And what do we want instead? What we really want is someone to try to see it from our perspective. And so what I asked that parent to do and what she ended up doing was when the next time the child had the the the meltdown because they didn't have a chance to kinda talk about it beforehand, the parent kinda went in with, oh my goodness. Jen Lumanlan [00:14:46]: I hear you. It's so hard to transition out of playtime with me. Right? Because it's so much fun, and you love it so much. And now we're going to pick up your sibling, and for the rest of the afternoon, you're gonna have to share me. You're gonna have to wait. You can't just have the thing that you want right at the moment that you want it. Is that what's going on for you? And the kid is like, yes. And we're done. Jen Lumanlan [00:15:05]: And there's no more hitting, and there's no more biting, and there's no more flailing on the floor because the child was heard. And so I'm not saying this magically fixes every tantrum in your child's life, but I can tell you that when you see these things coming, when you see, okay. Yeah. Every day at this time, my kid has a tantrum. Why is that? What need are they trying to meet? Can I help them meet that need? That takes care of, like, a massive chunk of them up front, so you never even get into the tantrum in the first place. And then once you're in it, then the empathy the okay. What's really going on for you? Can I sit with you in this hard time that you're having? And that's where you find the real beauty of, yes. I just wanted to be heard. Jen Lumanlan [00:15:45]: I just wanted somebody to acknowledge that it's hard for me to to stop playing with you and have to share you for the rest of the evening. Dr. Christopher Lewis [00:15:51]: So a lot of the examples you gave were of younger children. And in a perfect world, I would have loved to have had this book when my kids were really young. So if someone is hearing this and they're saying, I've got a tween, I've got a teen, and our relationship's not the best, we're in this fighting, we were fighting together, we're not seen eye to eye, you know, we're, you know, we're isolated, you know, we're we're not where we need to be. Are there things that they can do with this problem solving approach that they can start putting in place even though their children are not at that young age that they can start using right away? Jen Lumanlan [00:16:28]: Yes. It's never ever, ever too late to do this. I mentioned that my parenting role models were not the best, and I've thought about this a lot actually. And, you know, what would have happened I guess I do wanna be clear. You know, they were doing the best they could with the tools that they had. And if one of them had learned these tools and had tried to make some kind of shift, even in my late teenage years, would that have made a difference? Yes. It absolutely would have. And so where I would try to start with this kind of thing is to to try to kind of back off where you see that you're using power to get your child to change their behavior. Jen Lumanlan [00:17:04]: Not back off completely, but try to use a simple phrase. And that phrase is, I'm worried that dot dot dot. So if your, you know, your your kid is asking to do something, they wanna go out with friends, they whatever whatever is the thing that you're thinking about saying no to. That previously would you would have used your power, you would have made sure that they didn't do the thing that you that they're asking to do, that they really want do, that you don't want them to do. And so instead of of doing that, we can say, I'm worried that you're not gonna be safe. Right? I'm worried that this specific thing is going to happen. How can we make sure this thing doesn't happen? Because what what what the I'm worried that does is it helps me to articulate my need. I am worried for your safety. Jen Lumanlan [00:17:46]: If I can know that certain parameters are in place that mean that I think you're gonna be safe, then, yeah, I'm willing to say yes to this thing. Then I don't have to use my power over you to try and get you to change your behavior. I think that what what parents you're describing or seeing is I get actually reading for the first time doctor Thomas Gordon's book on, parent effectiveness training, and he talks about power and influence. And when we've used power over our children for a long time, we tend to find we have less influence as they get older because people don't like being influenced by people who have used power over them. And so if we want to have influence over our children as they get older and and they realize, you know what? You don't you actually don't have any power over me anymore. I'm getting bigger to the point where you can't physically intimidate me, and once I have the car keys, right, I'm done. I'm out of here. You can't control me anymore. Jen Lumanlan [00:18:37]: And if we still want to be able to influence our children at that point, we have to be willing to give up some of that power, and I'm worried that is a great place to start with that. Dr. Christopher Lewis [00:18:47]: One of the other things that you talk about in the book is that many of the triggers, the triggers that all of us have internally, the things that set us off in our own parenting journey with our kids stem from how we were raised. How can parents begin to unpack and heal from their own childhood experiences to become more conscious, connected parents? Jen Lumanlan [00:19:09]: Well, that could be another episode by itself. So, I mean, there's a lot there. And what parents that I work with tend to find is that they are most triggered by their child's behavior when they when their child gets to an age where they were having a hard time with their parents. So there's, you know, all the typical toddler stuff that is just hard when the toddler is resisting for the first time, and we used to resist as well. Right? We didn't like it either, being told what to do and that my way is the only way and that even if we try and kind of be nice about it, that ultimately, the kid's gonna do things the way that we want them to do. We didn't like that either. We pushed back against it. And, eventually, we learned there's no point in pushing back because the parent's gonna win eventually. Jen Lumanlan [00:19:50]: And so you know, most people find that stage difficult for that reason. And then as we go through life, there was probably an age where we kinda butted up against our parents for for whatever reason. And then when our child gets to that age, then we remember all those struggles. It's like they're they're right here again. They're right here with us, and they remind us of the hard time that we had, the ways that we were dominated by our parents. And I think this, it's especially difficult actually for parents who have done a little bit of work, who are trying to do things differently with their child. Because when their child is doing something the parent finds difficult, there's this kind of tug of war happening in their heads. There's this, I know what my values are. Jen Lumanlan [00:20:31]: I know how I want to raise you. I want to be in this power sharing relationship with you, but I would have been punished for doing the thing you just did. If I never spoken to my parent like that, right, they would have hit me. And so it's like there's this this massive, you know, you can imagine this tug of war literally happening inside of our heads. And and it's happening in this moment when our kid is doing something we told them not to do. And the amount of mental capacity it takes to be able to navigate that and also be calm for your child and show up for your child is is overwhelming, and so we snap. And so that's why I teach a whole 10 week workshop called taming your triggers on where does this stuff come from, really digging deep and to start healing those things so that we don't have to carry around the weight of that hurt every day. And, also, really digging deep into the the tools that I've been mentioning that are described in the book and, like, how do we actually use them when I'm feeling triggered? Right? How do I how do I create a pause? Because that's that's the critical phase for especially for people who are triggered, is creating that pause between the thing my child does and my reaction. Jen Lumanlan [00:21:42]: And once you have that pause, then you have a moment to be able to say, okay. What are my values here? What's really important to me? What is my need? Okay. This is it. And so the thing that's gonna come out of my mouth is gonna be x rather than, you know, whatever it is that currently flies out in the moment that our child does this thing right now. Jen Lumanlan [00:22:00]: And so many times, it is that latter aspect. Jen Lumanlan [00:22:03]: And so often, it's your parents' voice that comes out. You're like, where did that come from? Yes. Because our parents raised us using these tools. They they dominated us. Even if they didn't mean to, even if they were doing the best that they could, they dominated us. And so when we're in these stressed moments, the thing that comes out is the thing that was modeled for us. Dr. Christopher Lewis [00:22:22]: You know, the final thing that I think that I'd mentioned is that in your book, you really talk about transforming the family dynamic and that you say that through transforming this dynamic within our own homes, we can contribute to what you call a broader societal change. So how do you envision parents using these parenting tools to raise children who are capable of challenging system systematic injustices in the world around them? Jen Lumanlan [00:22:48]: Yeah. I mean, I see it happening already in the parents that I work with. And there's an example in the book of a parent who parent Maria and her her daughter, Isabelle. And, you know, Isabelle is one of those kids who, from the get go, knew exactly what she wanted and would scream if you held her the wrong way and would refuse to put her shoes on as a toddler. Right? Even even to go to a a nice outing. Right? The parents are like, okay. Put your shoes on. Well, no. Jen Lumanlan [00:23:13]: You told me to do it. No. I'm not doing it. And they stand there and stand off for half an hour, and the kid's not doing anything, and and they never make it out. And so Maria very quickly realized that using these power over tools was just gonna result in endless repetitions of that situation and started using these power sharing tools. And the transformation in their own relationship has been really profound. I mean, this is a kid who, I think Maria actually sprained her ankle in the house one day, and Isabelle stepped over her and said, you know, what? What's for lunch? No empathy, no compassion, no nothing. And within a period of months, right, we see empathy, we see compassion start coming out. Jen Lumanlan [00:23:57]: We see the kids all around the table, and some of the kids are teasing mom. And and Isabelle says, I'm looking at mom, and it seems like she's not up for being teased right now. Right? Reading mom's cues and being able to say, you know what? I'm not seeing that that mom's really into this. And so that's just within the family. And then we look outside the family, and Isabel sees that there's a kid in the school who has ADHD and is being bullied by the peer group that Isabelle is a part of, and Isabelle says, you know what? No. I'm not I'm not gonna do that. I'm not gonna be part of this group and goes over and makes friends with a kid with ADHD. So that's, you know, that's a super small example. Jen Lumanlan [00:24:32]: And then we start to extrapolate that out to other systems in the world. Right? If we think about things like racism, it's ultimately a power over system. It's me saying, my right to exist as a white person, to be comfortable as a white person is more important than people of color's right to exist in their whole selves. And what if we were to say, you know what? Your needs are just as important as my needs. I don't believe that these systems of domination out in the world can exist when we all perceive each other's needs to be equally as important as our own. And so, yes, it's gonna take some time. Right? This can't be the only way we go about doing these things. Parents are not responsible in themselves by, you know, just alone for solving these societal challenges. Jen Lumanlan [00:25:16]: We also need lots of other work as well. But I truly believe that seeing each other's needs as as important as our own is a critical piece of making the world a place where everybody can thrive. Jen Lumanlan [00:25:30]: I really appreciate you sharing everything that you've been sharing today. And if people want to find out more about you, your podcast, your book, where's the best place for them to go? Jen Lumanlan [00:25:40]: So everything I do flows through your parentingmojo.com. I would definitely advise parents to go check out the quiz at your parentingmojo.comforward/quiz. Because once you know your child's needs, everything just gets so much easier. Because as soon as you see resistance, you can say, okay. Where is this coming from? Is it a need? Oh, yes. It's autonomy. It's connection. It's, you know, whatever that cherry need is. Jen Lumanlan [00:26:03]: And then you can very quickly find the strategies that meet their need instead of having to look through the list of 50 needs and say, oh, which one is it? So I would definitely recommend that. I am on Facebook and Instagram. I don't use them super much, but I am there as well. And so, yeah, subscribe to podcast episodes as well, through the through the website. And the book is at Parenting Beyond Power. Dr. Christopher Lewis [00:26:25]: Well, I really appreciate you sharing all of this today for what you're putting out into the world and what you're doing to help parents be better parents, and I wish you all the best. Jen Lumanlan [00:26:32]: Thanks so much, Chris. It was great to be with you. Dr. Christopher Lewis [00:26:34]: If you've enjoyed today's episode of the Dads with Daughters podcast, we invite you to check out the Fatherhood Insider. The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step roadmaps, and more, you will engage and learn with experts, but more importantly, dads like you. So check it out at fatheringtogether.org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with daughters is a program of fathering together. We look forward to having you back for another great guest next week, all geared to helping you raise strong, empowered daughters and be the best dad that you can be. Dr. Christopher Lewis [00:27:32]: We're all in the same boat, And it's full of tiny screaming passengers. We spend the time. We give the lessons. We make the meals. We buy them presents and bring your a game. Because those kids are growing fast. The time goes by just like a  

Dr. Nathan Pennell and Dr. John Sweetenham discuss the evolving landscape of oncology in 2025 and the challenges oncologists will be facing, including the impact of Medicare drug price negotiations, ongoing drug shortages, and the promising role of AI and telehealth in improving patient outcomes and access to clinical trials. TRANSCRIPT Dr. John Sweetenham: Hello, I'm Dr. John Sweetenham, the host of the ASCO Daily News Podcast. 2025 promises to be a year of continued progress in drug development, patient care, and technological innovations that will shape the future of cancer care. Oncologists will also be grappling with some familiar challenges in oncology practice and probably face a few new ones as well. I'm delighted to be joined today by Dr. Nathan Pennell to discuss some of these challenges. Dr. Pennell is the co-director of the Cleveland Clinic Lung Cancer Program and vice chair of clinical research at the Taussig Cancer Center. He also serves as the editor-in-chief of the ASCO Educational Book.  You'll find our full disclosures in the transcript of this episode.  Nate, it's great to have you on the podcast today. Dr. Nathan Pennell: Thanks for inviting me, John. I'm excited to be here. Dr. John Sweetenham: Thanks. So, Nate, we've been hearing a lot recently about implementation science in oncology particularly. This has been the case, I would say, over the past decade and of course the goal is to how do we figure out the best way to integrate evidence-based practice into oncology care? There's been a lot of very good guidance from organizations like ASCO and every year we're reminded of the need for clinical decision support for practicing oncologists at the point of care. Although I think we all agree it is the right thing to do, and this has been a matter of discussion for probably more than 10 years, for the most part, I don't think we've really got there. Some big practices probably have a truly well-integrated clinical decision support tool, but for many of us this is still lacking in the field. I wonder whether we do need some kind of global clinical decision support tool. What do you think about the future of clinical decision support at the point of care? And do you think this is going to continue to be a need? Dr. Nathan Pennell: I think that's a fantastic question and it absolutely is something we're going to continue to work towards. We're in an incredibly exciting time in oncology. We've got all these exciting predictive biomarkers, effective treatments that are working better than anything we've had in our careers up to this point. But when we actually look to see who is benefiting from them, what we find is that outside of clinical trial populations, many of our patients aren't actually accessing these. And so publications that look at real-world use of these, one that jumps to mind for me is a publication looking at biomarker testing for driver oncogenes in lung cancer showed that while everyone who treats lung cancer says, “Absolutely, we need to test for biomarkers such as EGFR mutations,” in the real world, probably only slightly over a third of people ever access these drugs because there are so many different gaps in care that fall through the cracks. And so decision support is absolutely critical.  You mentioned this has been going on for a decade. Actually, the Institute of Medicine in 2013 recommended that with the uptake of electronic medical records, that we move forward with building these true learning health care systems that would improve quality and use every patient's information to help inform their care. And in 2023, as a representative of ASCO, I was able to look back at the last decade, and the uniform conclusion was that we had failed to build this learning health care system. So, what can we do going forward? The good news is there are improvements in technology. There are, for better or for worse, some consolidation of electronic medical records that has allowed larger numbers of patients to sort of have data sets shared. ASCO started CancerLinQ to try to improve quality, which is now part of OpenAI, and is still working on technology solutions to help provide decision support as we are better able to access patient data. And I think we're going to talk a little bit later about some of the technological advances that are going on in artificial intelligence that are really going to help improve this. So I think this is very close to impacting patient care and improving quality of care. I think for, as you'd mentioned, large health care systems and users of the major EMRs, this is going to be extremely close. Dr. John Sweetenham: Thanks, Nate. And just to extend the conversation into another area, one of the constant, I think, pain points for practicing oncologists has been the issue of prior authorization and the amount of time and energy it takes to deal with insurance denials in cancer care. And I think in a way, these two things are linked in as much as if we had clinical decision support tools at the point of care which were truly functional, then hopefully there would be a more facile way for an oncologist to be able to determine whether the patient in front of him or her is actually covered for the treatment that the oncologist wants to prescribe. But nevertheless, we're really not there yet, although, I think we're on the way to being there. But it does remain, like I said, a real pain point for oncologists.  I wonder if you have any thoughts on the issue of prior authorization and whether you see in the coming year anything which is going to help practicing oncologists to overcome the time and effort that they spend in this space. Dr. Nathan Pennell: I think many oncologists would have to list this among, if not the least favorite aspects of our job these days is dealing with insurance, dealing with prior authorizations. We understand that health care is incredibly expensive. We understand that oncology drugs and tests are even more expensive, probably among, if not the most rapidly growing costs to the health care system in the U.S., which is already at about 20% of our GDP every year. And so I understand the concern that costs are potentially unsustainable in the long term. Unfortunately, the major efforts to contain these costs seem to have fallen on the group that we would least like to be in charge of that, which are the payers and insurance companies, through use of prior authorization. And this is good in concept, utilization review, making sure that things are appropriate, not overutilizing our expensive treatments, that makes perfect sense. Unfortunately, it's moved beyond expensive treatments that have limited utility to more or less everything, no matter how inexpensive or standard. And there's now multiple publications suggesting that this is taking on massive amounts of time. Some even estimated that for each physician it's a full 40-hour work week per physician from someone to manage prior authorizations, which costs billions of dollars for practices every year. And so this is definitely a major pain point.  It is, however, an area where I'm kind of optimistic, maybe not necessarily in 2025, but in the coming several years with some of the technology solutions that are coming out, as we've talked about, with things like clinical pathways and whatnot, where the insurance company approvals can be tied directly to some of these guideline concordance pathway tools. So the recent publication at the ASCO Quality [Care] Symposium looking at a radiation oncology practice that had a guideline concordant prior auth tool that showed there was massive decrease in denials by using this. And as this gets rolled out more broadly, I think that this can increase the concept of gold carding, where if practices follow these clinical guidelines to a certain extent, they may be even exempt from prior authorization. I think I can envision that this is very close to potentially removing this as a major problem. I know that ASCO certainly has advocated on the national level for changes to this through, for example, advocating for the Improving Seniors Timely Access to Care Act. But I think, unfortunately, the recent election, I'm not sure how much progress will be made on the national level for progress in this. So I think that the market solutions with some of the technology interventions may be the best hope. Dr. John Sweetenham: Yeah, thanks. You raised a couple of other important points in that answer, Nate, which I'll pick up on now. You mentioned drug prices, and of course, during 2025, we're going to see Medicare negotiating drug prices. And we've already seen, I think, early effects from that. But I think it's going to be really interesting to see how this rolls out for our cancer patients in 2025. And of course, the thing that we can't really tell at the moment that you've alluded to is how all this is going to evolve with the new administration of President Trump. I understand, of course, that none of us really knows at this point; it's too early to know what the new administration will do. But would you care to comment on this in any way and about your concerns and hopes for Medicare specifically and what the administration will do to cancer care in general? Dr. Nathan Pennell: I think all of us are naturally a little bit anxious about what's going to happen under the new administration. The good news, if there's good news, is that under the first Trump administration, the National Cancer Institute and cancer care in general was pretty broadly supported both in Congress and by the administration. And if we look at specifically negotiating drug prices by Medicare, you can envision that having a businessman president who prides himself in negotiations might be something that would be supported and perhaps even expanded under the incoming Trump administration. So I think that's not too hard to imagine, although we don't really know. On the other hand, there are very valid concerns about what's going to happen with the Affordable Care Act, with Medicaid expansion, with protections for preexisting conditions, which impact our patients with cancer. And obviously there are potential people in the new administration who perhaps lack trust in traditional evidence-based medicine, vaccines, things like that, which we're not sure where they're going to fall in terms of the health care landscape, but certainly something we'll have to watch out for. Dr. John Sweetenham: Yeah. Certainly, when we regroup to record next year's podcast, we may have a clearer picture of how that's going to play out. Dr. Nathan Pennell: I mean, if there's anything good from this, it's that cancer has always been a bipartisan issue that people support. And so I don't want to be too negative about this. I do think that public support for cancer is likely to continue. And so overall, I think we'll probably be okay. Dr. John Sweetenham: Yeah, I agree with that. And I think one of the things that's important to remember, I do remember that one of the institutions I've worked at previously that there from time to time was some discussion about politics and cancer care. And the quote that I always remember is “We all belong to the cancer party,” and that's what's really important. So let's just keep our eye on the board. I hope that we can do that.  I'm going to switch gears just a little bit now because another issue which has been quite prominent in 2024 and in a few years before that has been supply chain issues and drug shortages. We've seen this over many years now, but obviously the problems have apparently been exacerbated in recent years, particularly by climate events. But certainly ASCO has published some recommendations in terms of quality care delivery for patients with cancer. Can you tell us a little bit about how you think this will go in the coming year and what we can do to address some of the concerns that are there over drug shortages? Dr. Nathan Pennell: Yeah. This continues to be, I think, a surprising issue for many oncologists because it has been going on for a long time, but really hasn't been in the public eye. The general problem is that once drugs go off patent and become generic, they often have limited manufacturers that are often outside the U.S. sometimes even a single manufacturer, which leaves them extremely vulnerable to supply chain disruption issues or regulatory issues. So situations where the FDA inspects and decides that they're not manufacturing things up to snuff and suddenly the only manufacturer is temporarily shut down. And then as you mentioned, things like extreme weather events where we had Hurricane Maria hit Puerto Rico and suddenly we have no bags of saline for several months. And so these are major issues which I think have benefited from being in the public eye.  ASCO, on the one hand, has, I think, done an excellent job leading on what to do in scenarios where there are shortages. But I think more importantly, we need more attention on a national level to policy changes that would help prevent this in the future. Some suggestions have been to increase some of the oversight of the FDA into supply chain issues and generic drugs, perhaps forming more of an early warning system to anticipate shortages so that we can find workarounds, find alternative suppliers that perhaps aren't currently being widely utilized. We can advocate for our legislators to pass legislation to support drug production for vital agents through things like long term contracts or even guaranteed pricing that might also even encourage U.S. manufacturers to take back up generic drugs if they were able to make it profitable. And then finally, I think just more of a national coordinated approach rather than the piecemeal approach we've done in the past. I remember when we had a platinum [drug] shortage last year. Our institution, with massive resources in our pharmacy, really did an excellent job of making sure that we always had enough supply. We never actually saw that shortage in real time, but I know a lot of places did not have those resources and therefore were really struggling. And so I think more of a coordinated approach with communication and awareness so that we can try to prevent this from happening. Dr. John Sweetenham: Thanks, Nate. And you raised the issue of major weather events, and I'd like to pick up on that for just a moment to talk about climate change. We now know that there is a growing body of evidence showing that climate change impacts cancer care. And it does it in a lot of ways. I mean, the most obvious is disrupting care delivery during one of these major events. But there are also issues about increased exposure to carcinogens, reduced access to food, reduced access to cancer screenings during these major disasters. And the recent hurricanes, of course, have highlighted the need for cancer centers to have robust disaster preparedness plans. In addition to that, obviously there are questions about greenhouse gas emissions and how cancer centers and health care organizations handle that.  But what do you see for 2025 in this regard? And what's your thinking about how well we're prepared as deliverers of cancer care to deal with these climate change issues? Dr. Nathan Pennell: Yeah, that is sobering to look at some of the things that have happened with climate change in recent years. I would love to say that I think that from a national level, we will see these changes and proactively work to reduce greenhouse emissions so that we can reduce these issues in the future. I'm not sure what we're going to see from the incoming administration and current government in terms of national policy on changes for fossil fuel use and climate change. I worry that there's a chance that we may see less done on the national level. I know the NCI certainly has policies in place to try to study climate change impact on cancer. It's possible that even that policy could be impacted by the incoming administration. So we'll have to see.  So, unfortunately, I worry that we may be still dealing in a reactive way to the impacts of this. So, obviously, wildfires causing carcinogens, pollution leading to increased cancer incidence, obviously, major weather events leading to physical disruptions, where cancer centers definitely have to have plans in place to help people maintain their treatment during those periods. As an individual, we can certainly make our impact on climate change. There are certainly organizations like Oncologists United for Climate and Health, or so-called OUCH, led by Dr. Joan Schiller, a friend of mine in the lung cancer world, where oncologists are advocating for policies to reduce use of fossil fuels. But I don't know, John, I don't know if I'm hopeful that there's going to be major policy changes on this in the coming year. Dr. John Sweetenham: I suspect you're right about that, although I think on the positive side, I think the issue as a whole is getting a lot more attention than it was maybe even two or three years ago. So that has to be a good thing that there's more advocacy and more attention out there now.  Nate, before we go on to the last question, because I do want to finish on a positive note, I just wanted to mention briefly that there are a couple of ongoing issues which, when we do this podcast each year, we normally address, and they certainly haven't gone away. But we know that burnout and workforce issues in oncology will continue to be a big challenge. The workforce issues may or may not be exacerbated by whatever the new administration's approach to immigration is going to be, because that could easily significantly affect the workforce in oncology. So that's one issue around workforce and burnout that we are not addressing in detail this year. But I wanted to raise it just because it certainly hasn't gone away and is going to continue to challenge us in 2025.  And then the other one, which I kind of put in the same category, is that of disparities. We continue to see ethnic and racial disparities of care. We continue to see disparities in rural areas. And I certainly wouldn't want to minimize the challenges that these are likely to continue to present in 2025. I wonder if you just have any brief comments you'd like to make and whether you think we're headed in the right direction with those issues. Dr. Nathan Pennell: Well, I'm somewhat optimistic in some ways about burnout. And I think when we get to our final topic, I think some of that may help. There may be some technology changes that may help reduce some of the influences of burnout. Disparities in care, obviously, I think similarly to some of the other issues we talked about have really benefited from just a lot of attention being cast on that. But again, I actually am optimistic that there are some technology changes that are going to help reduce some disparities in care. Dr. John Sweetenham: It's always great to finish one of these conversations on a positive note, and I think there is a lot to be very positive about. As you mentioned right at the beginning of the podcast, we continue to see quite extraordinary advances, remarkable advances in all fields of oncology in the therapeutic area, with just a massive expansion in not only our understanding, but also resulting from that improved understanding of the biology of the disease, the treatment advances that have come along. And so I think undoubtedly, we're going to see continued progress during 2025. And I know that there are technology solutions that you've mentioned already that you're very excited about. So, I'd really like to finish today by asking you if you could tell us a little about those and in particular what you're excited about for 2025. Dr. Nathan Pennell: Yeah. It's always dangerous to ask me to nerd out a little bit about some of these technology things, but I don't think that we can end any conversation about technology and not discuss the potential for artificial intelligence (AI) in health care and oncology. AI is sort of everywhere in the media and sort of already worked its way into our lives in our phones and apps that we're using and whatnot. But some of what I am seeing in tools that are probably going to be here very soon and, in some cases, already arriving, are pretty remarkable.  So some of the advances in natural language processing, or NLP, which in the past has been a barrier to really mining the vast amounts of patient information in the electronic medical record, is so much better now. So now, we can actually use technology to read doctor's notes, to read through scanned PDFs in our EMRs. And we can imagine that it's going to become very soon, much harder to miss abnormal labs, going to be much harder to miss findings on scans such as pulmonary nodules that get picked up incidentally. It's going to be much easier to keep up with new developments as clinical guidelines get worked in and decision support tools start reminding patients and physicians about evidence-based, high-quality recommendations. Being able to identify patients who are eligible for clinical trials is going to become much more easy.  And that leads me to the second thing, which is, throughout the pandemic we have greatly increased our use of telehealth, and this really has the potential to reduce disparities in care by reaching patients basically wherever they are. This is going to disproportionately allow us to access rural patients, patients that are currently underrepresented in clinical trials and whatnot, being able to present patients for clinical trials. In the recent “State of Cancer Care in America” report from ASCO, more than 60% of patients in the U.S. did not have access to clinical trials. And now we have the technology to screen them, identify them and reach out to and potentially enroll them in trials through use of decentralized elements for clinical trials. And so I'm very optimistic that not just good quality standard cancer care, but also clinical research is going to be greatly expanded with the use of AI and telehealth. Dr. John Sweetenham: Really encouraging to hear that. Nate, it's been a real pleasure speaking with you today and I want to thank you for taking the time to share your insights with us on the ASCO Daily News Podcast.  Dr. Nathan Pennell: Thanks, John. Dr. John Sweetenham: I also want to say 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. Nathan Pennell @n8pennell   Dr. John Sweetenham   Follow ASCO on social media:    @ASCO on Twitter    ASCO on Facebook    ASCO on LinkedIn      Disclosures:   Dr. John Sweetenham:   Consulting or Advisory Role: EMA Wellness   Dr. Nathan Pennell:     Consulting or Advisory Role: AstraZeneca, Lilly, Cota Healthcare, Merck, Bristol-Myers Squibb, Genentech, Amgen, G1 Therapeutics, Pfizer, Boehringer Ingelheim, Viosera, Xencor, Mirati Therapeutics, Janssen Oncology, Sanofi/Regeneron    Research Funding (Inst): Genentech, AstraZeneca, Merck, Loxo, Altor BioScience, Spectrum Pharmaceuticals, Bristol-Myers Squibb, Jounce Therapeutics, Mirati Therapeutics, Heat Biologics, WindMIL, Sanofi  

Exploring the Role of Fathers in Pregnancy and Beyond In a heartwarming and insightful episode of the "Dads with Daughters" podcast, host Dr. Christopher Lewis chats with Matthew Morris, who shares his unique journey into fatherhood. Through experiences that span 15 countries, Morris does more than recount personal stories; he advocates for systemic changes in how fathers are supported during the pregnancy journey. Here's a deeper dive into the profound topics discussed in this enriching episode. The Discovery of Parenthood Matthew Morris and his wife Shannon found out they were expecting their first child in the most memorable way. Following an offhand Mother's Day comment, a series of pregnancy tests confirmed the joyous news. As fate would have it, the couple discovered they were having a girl at a family gathering through a creative, heartwarming gender reveal—Matthew dyed his hair pink to share the news. A Journey Across Continents Before settling into parenthood, the adventurous couple decided to travel to 15 countries, immersing themselves in different cultures and learning global perspectives on pregnancy and childbirth. They planned their destinations whimsically; Brazil if a boy, Thailand if a girl, turning every step into an adventure. Their travel decisions were also influenced by significant life changes, including job losses and leaving active military duty. These pivotal moments pushed them forward into the next chapter of their lives. Navigating Healthcare and Birth The Morris's initial plan was to have their baby in Denmark, attracted by the progressive and cost-effective healthcare system. However, visa issues forced them back to the U.S. at 35 weeks pregnant. Matthew expressed strong critiques of the U.S. healthcare system's support for childbirth, and particularly its lack of resources for fathers. Ultimately, Shannon opted for a home birth in their Chicago apartment, supported by a midwife and a doula. This experience emphasized the importance of having a birthing team that values the father's role—Matthew even got to "catch" his daughter when she was born on February 2nd, 2024. Advocacy for Doulas and Progressive Paternity Leave From their global travels, Matthew observed how other countries treat pregnancy as a natural life event rather than a medical condition. He strongly advocates for the inclusion of doulas and midwives in insurance coverage, given their essential role in supporting both parents. His experiences highlighted the stark differences in parental leave policies worldwide, with some countries offering up to 24 months of government-supported leave—a far cry from the limited options in the U.S. The Birth of a Book Inspired by their journey, Matthew authored "The Partner's Purpose During Pregnancy." This practical guide offers straightforward, actionable steps to help expectant fathers get involved early and remain supportive throughout the pregnancy. Matthew's insights are geared towards making the transition into fatherhood less daunting, emphasizing the importance of preparation and involvement. Matthew Morris's journey into fatherhood is a testament to the importance of an involved and supportive parenting partner. His stories and insights underscore the need for systemic changes in how we support fatherhood and childbirth in the U.S. For fathers looking to connect and learn, resources like the "Dads with Daughters" podcast and the "Fatherhood Insider" offer invaluable support. For more from Matthew Morris, visit his website at www.thepartnerspurpose.com and follow him on Instagram at @thepartnerspurpose. TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Christopher Lewis [00:00:16]: Welcome back to the Dads with Daughters podcast where we bring you guests to be active participants in your daughters' lives, raising them to be strong, independent women. Really excited to have you back again this week. As always, every week, you and I are on this journey together. You know, I've got 2 daughters, you've got daughters, and we are all rolling in the same direction. We're all working to raise those strong, independent women that we want for our daughters to become. And hopefully, by now, after 250 episodes that we've had of this podcast, you know that we cannot do this alone. You and I cannot do this alone. We have to be able to rely on others. Christopher Lewis [00:00:55]: We have to be able to rely on working with one another to be able to lift each other up, to be able to learn and grow from each other, to be able to be the dads that we want to be. None of us have all of the tools, have all of the understanding. None of us have the perfect manual to follow to be that great dad that you want to be. But this podcast is here to be able to give you some, some hints, some tips, some things that you can do to be able to be that father that you want to be. So every week I bring you different guests, different people, people with different experiences, fathers, mothers, other people with resources that can help you to be able to see fatherhood in a little bit different way, provide you some tools for your toolbox, and help you to be able to become that father that you want to be. This week, we got another great guest with us today. Matthew Morris is with us today. Really excited to have him here. Christopher Lewis [00:01:49]: And we're gonna be talking about his own journey in becoming a father. And prior to becoming a father, he and his wife traveled to 15 countries to learn about parenthood and preparation for the birth of their daughter this past February. And, as he says, it's been a wild ride. And I think for every father, it's a wild ride when you lead up to to to fatherhood. And and once your daughter's here, it becomes an even greater ride, and it continues to go on throughout their lives. So I'm really excited to have him here today to talk about fatherhood, talk about his own journey and a little bit more, and to introduce him to you. Matthew, thanks so much for being here today. Matthew Morris [00:02:28]: Thank you, Christopher. Glad to be here. Christopher Lewis [00:02:29]: It is my pleasure having you here today. Glad that you and I were able to connect and be able to have you talk about your own journey. And one of the first things that I always love to do is turn the clock back in time. So I wanna go back to that first moment that you found out that you were going to be a father to a daughter. What was going through your head? Matthew Morris [00:02:46]: My wife was standing at the top of the staircase, and I had just walked in the door, and I heard her scream. And my wife is a hardcore former United States Navy veteran, and she just, like, even keel all the time. Things do not rile her. And when I heard, bat, yeah, from the top of the staircase, I thought one of 2 things has happened. I said, okay. The house is being breached, and we are about to go on the defense, or she's pregnant. And sure enough, I look up, and she has 3 pregnancy tests in her hands like Wolverine. And I am I book it up the stairs, and she looks at me, and she's like, can you see the pink line? Can you see it? And mind you, my eyes aren't what they used to be. Matthew Morris [00:03:41]: I'm looking. I'm like, may maybe. I think so. And she goes, okay. You pee on 1, and then we'll know. And so shortly that was right after Mother's Day last year. And we were coming back from a wedding, and a woman had wished Shannon. She said happy Mother's Day. Matthew Morris [00:04:02]: And Shannon was like, I'm not a mom, and and we were walking away. And she kinda elbowed me and was like, wouldn't it be funny if and so I found out initially that that she was pregnant and went in a few weeks later to to verify everything. And then then we knew she was pregnant. Obviously, didn't know it was gonna be a little girl until a few months later. And the way that we found out that it was gonna be a little girl was we were we were at a family reunion with Shannon's family. It was a birthday party. And she gets an email, and we're we're sitting all sitting around kinda talking, talking. And, again, Shannon Shannon does not get super excited or super emotional about anything. Matthew Morris [00:04:50]: She's so just level headed. And and she puts her phone down. She looks at me and goes, we gotta go. And I said, why? What was going on? She goes, I know what we're gonna have. And I said, you mean for dinner? She goes, no. For the rest of our lives. And I said, okay. So we say goodbyes, and we go to the haircare store, and she buys a bottle of blue hair dye and a bottle of pink hair dye. Matthew Morris [00:05:22]: And we go to her parents' house, and we said, here's Matthew what we're gonna do. I'm gonna blindfold you. I'm gonna dye your hair one color or the other, and that is how we are going to do the gender reveal. And I have a very proud mohawk. And so if you go on her Instagram, there's a hilarious video of me blindfolded and Shannon with bright pink hair dye, and I take the blindfold off. And as soon as she hands me in the mirror, well, the sun's behind me, so I look in the mirror, and it just blinds me. So I can't even say I can't even tell what I'm looking at myself. And finally, I look around and I see it's pink, and then that's that's how we found out. Matthew Morris [00:06:04]: So that was kind of the the spark to our international journey. And now so we're in fast forward. That was a little over a year ago. We come back to now. Shannon and I made a bet. We have a little boy, we're going to Brazil. And if we have a little girl, we're gonna go to Thailand. And so right now, as we are wrapping up our adventure in Chicago, we are prepping to set sail for title. Matthew Morris [00:06:31]: And so that in between everywhere that we went from the beginning of 2023 to now. And we had to work through our personal endeavors. So January, February of 2023, Shannon was the tech layoff, and then we found out Shannon was pregnant in April of 2023, and then my separation from the marine corps came in June of 2023. And so we went from dual income, no kids, to dual unemployed with a baby on the way. And there is nothing that is a better catalyst for it's time to grab life by the horns than realizing, hey. We gotta figure out somehow to eat. And with that, and this comes into the fatherhood aspect, in our study of how childbirth and the medical system of childbirth in the United States is so far behind the rest of the world, unfortunately, we actually made the decision that we didn't wanna have the baby in the States. And that was a big part of why we left the country. Matthew Morris [00:07:45]: So our original plan was to have Maven in Denmark because Denmark, Sweden, that region has a extremely progressive and much safer approach to childbirth, and it's also significantly cheaper. Even with the cost of flying over there, living temporarily, and paying for the birth out of pocket, all of that would still have been cheaper than going through an uninsured birth in a US medical system. And the big challenge for us was coming off of active duty where almost all of your medical is paid for. When that came to an end, we didn't have health insurance for childbirth. And so what is normally nothing out of pocket with your insurance policy is between $3,025 total to have a baby in the United States. And in addition to that, the restrictions that are put on expecting moms when they are going through, the tests that are mandatory, the lack of education for dads and partners or birthing partners or whoever that person is that is supporting mom through her pregnancy. It's such an afterthought in the United States, which is what set us off on putting the information together for the partner's purpose during pregnancy. So fast forward a few months, our visas were not processed properly, and so we had to come back to the United States when Shannon was 35 weeks pregnant. Matthew Morris [00:09:31]: Well, the FAA won't let you travel at 36 weeks. So it was either be considered an illegal immigrant in a foreign country where we were having a baby or hightail it back to the United States and try and get connected with a midwife and doula team here, which fortunately, we did. So Shannon made the decision that she wanted to have a midwife and doula guided home birth. And so in our apartment in Lincoln Park, Chicago on February 2nd, 2024 at about 1:45 AM. She gave birth with no meds, no anesthesia, just the raw power of being the woman that she is to our daughter. And our birth team coached me through, and I actually got to catch my daughter. I was the quarterback before the hike and had her in my arms and then passed her to the midwife to do all of the immediate post birth things. And baby is healthy and just a a little tornado right now.   Matthew Morris [00:12:56]: And that divide and conquer team, I stand beside and advocate for work on it. And part of what we're also trying to advocate for is the use of doulas and midwives to be covered by general insurance. Because that is a big reason why so many people don't use them is because it's not considered a necessary medical expense. Well, my advocation to that is it is. It is just as important for the birthing or the pregnancy for me to have someone that I can ask questions of, that I can go to, that has experience so that Shannon didn't have to in dealing with with pregnancy brain or brain fog or exhaustion or all of the stress that your body and mind undergo during pregnancy, I had a person that I could ask these questions of, get the answers for so that she could focus on her health and the health of the baby. Christopher Lewis [00:13:57]: So I guess one of the questions that I would ask, with that whole journey is you took a number of months while she was going through that pregnancy, as you said, to be able to learn more about pregnancy, learn more about what happens in other countries to be able to create this book that you've created. And I know that you were out for, I think it was 41 weeks, you said you went to 15 countries. And I guess let's talk on the high level. What are some of the biggest things that you learned in going to those different countries, seeing what other countries do in comparison to what happens in the United States? Matthew Morris [00:14:38]: So saying we were mostly in Sangin. And by and large, there is a different mindset in the way that pregnancy and pregnant people are viewed. My biggest lesson, my biggest learning point was that pregnancy is not a disease. In the United States, we treat pregnancy as a disease. A pregnant mom is looked at as having symptoms. Well, symptoms are the byproduct of illness as opposed to what I viewed there was pregnancy is just part of life. It's the natural progression of all things culminating in birth, and because it's treated so much differently, you have significantly lower rates of things like postpartum depression, you have a lower infant mortality rate, you have a lower maternal mortality rate. The other piece is the recovery time. Matthew Morris [00:15:45]: So commonly referred to as maternity leave, paternity leave, and what's referred to as nesting leave. Now in the United States, all of your leave comes from the company. In these areas, the leave is partially compensated by a government organization. So if you take the longest that we saw was 24 months of total family leave, and that leave could be used by either parent, either during or after the pregnancy, and and there was no expiration date. So imagine in the states, you can't even fathom that. The longest publicly traded company that we have found in the United States is 18 weeks. And that's good. That's better for our area. Matthew Morris [00:16:44]: But the question that we continue to ask is if you are trying to advocate for employees to come back and remain loyal, what are the things that you're doing to incentivize them? And what stands out more than anything is companies that that advocate for more family recovery time. And that's the biggest difference that we've seen from overseas to the states.   Christopher Lewis [00:17:08]: I appreciate you sharing that. And now that you I have transitioned into being a dad, a dad of a daughter, I talk to a lot of dads that step into fatherhood. And fatherhoods can be scary just in its own right in being able to step into that new persona and being able to be there for your child. I hear from a lot of dads with daughters that there's a particular fear of being a father to a daughter. And I guess for you, what's your biggest fear in being a father to a daughter? Matthew Morris [00:17:38]: That when she comes of age, she will come to me and say, father, I am not prepared to go out on my own. And that encompasses a lot. And when I say come of age, there's not a number that's associated with it. She might be ready to set out on her own at 13. She might not be ready to set out on her own until she's 20. Her development is going to happen on its own timeline. My responsibility as a dad is to hold her hand until it's time to let go. And when it's time to let go, I have to have given her every ounce of me so that she's ready. Matthew Morris [00:18:20]: Does that mean that it's gonna be smooth sailing and she's gonna have no trials of her own, and she's never gonna be in a situation where she has to fight for herself or for the other people that she loves and believes in? Absolutely not. But when it's time for her to fight, she is ready. Christopher Lewis [00:18:37]: That's fair. Now as I mentioned, you have put together this book, this book that you're putting out into the world to be able to help other dads, the partner's purpose during pregnancy. Talk to me about that and why you decided that you wanted to take the time to be able to put all of this learning into this, and what are you hoping that people are gonna take out of it? Matthew Morris [00:18:57]: Joshua Sharfstein (zero zero four:fifty seven): I put the partner's purpose during pregnancy together. Number 1, it was my personal way of processing. So on the fortunate side of being unemployed for that period of time, it gave me the head space to sit down and start asking really hard questions, to start reading the books. Right? I read all of them. I read what to expect when you're expecting, the birth partner, bumpin', misconceptions, the Mayo Clinic's guide to pregnancy. Oh, boy. Let me tell you. If, if you're looking for a captivating read, sit down and and pop that 600 pager open. Matthew Morris [00:19:35]: But the reason that I did was I treated Shannon's pregnancy and the birth of my daughter as my new mission. When we would fly in the marine corps, you would prep for sometimes weeks for one specific mission. And you would begin building that knowledge base of the operating area, the weapon systems that you were going to employ, the teammates that you were going to be fighting with and supporting, and the enemy that had a say in every action that you made, well, this was my new mission. And for me to process the intensity of watching Shannon's body change, watching her mindset on things change, I had to have an outlet. And my outlet was putting a pen to paper because when I was asking some of these questions from the point of view of an expecting dad, there were no answers. And fortunately, there is now a culture shift in the United States away from the way that our dads were were kinda forced into it. And what I mean by that is I have a very loving and supportive father. Shannon has a very loving and supporting father, but there was no such thing as dad being there after the baby was born. Matthew Morris [00:21:00]: Took mom to the hospital, baby was born, and 2, 3 days later, dad's back at work. And that's just the way it was. Well, now one of the positives from COVID is the acknowledgment of remote work and the fact that so many jobs can be done from home, which allows you the opportunity to be in proximity to your kids for a longer period of time. And with Partner's Purpose, our mission is to show that you can have a faster postpartum recovery period. You can reduce postpartum depression and other maternal mental health situations if you start being involved and educated way before baby comes. And the other piece is the books that I listed, they have a place on my bookshelves, and I'm not saying that if you are in this phase of birth not to go study them. Go. Do it. Matthew Morris [00:22:42]: And it's practical. It's not theoretical. It's not big universe things. It's tangible. It's make your birth plan together. It's read out loud to your baby before you go to sleep. It's make her a sandwich. It's let her cry. Matthew Morris [00:23:00]: It's these things that when you're in a stressful situation or sorry. When you're in a a calm situation, it's like, oh, yeah. That makes sense. But pregnancy is stressful for both parties involved. And so when we can lay out, do this, do this, do this, I am taking that thought out and replacing it with very basic, simple muscle memory. It's just like training. Marine Corps, you do rifle training. You learn every single in and out aspect of your weapon so that when you are in an extremely high stress environment, you don't have to stop and think, wait, hang on. Matthew Morris [00:23:40]: How do I take it off safety? How do I aim? No. You can be running on 36 hours of no sleep and half a stale piece of bread, and you still know how to make your weapon function when you need it to function. Maybe not that extreme in the average American pregnancy, but the concepts are the same. If I can lay your steps out for you, if I can show you ways to be involved, then all you have to do is pick it up, open it to any page and say, I know how to filter your feed. It's one of the other notes. I know how to invest in our education so that we can develop informed opinions, so that we can build our birth team together. So that if the doctor or the midwife or the doula or the nurse practitioner tells us we have to do something, we know what that means, and we can ask questions on if we really do have to do that or, and this is my favorite, we've always done it that way, so that's why we do it. Well, just because something has always been done does not necessarily mean it's the right way. Christopher Lewis [00:24:49]: Now we always finish our interviews with what I like to call our fatherhood 5 where I ask you 5 more questions to delve deeper into you as a dad. Are you ready? Matthew Morris [00:24:56]: Yes, sir. Let's do it. Christopher Lewis [00:24:57]: In one word, what is fatherhood? Matthew Morris [00:24:59]: Exciting. Christopher Lewis [00:25:00]: Let's think down the road, 18, 20 years. If I was to talk to your daughter, how would you want her to describe you? Matthew Morris [00:25:06]: Empowering and encouraging. I want her to, at no point, ever question if I have her back. I also acknowledge that probably is going to mean there are going to be moments where she is pissed at the decisions that I make. But if I've set her up for success to take on the world whatever way she chooses to take it on, then good. I have done my job. Christopher Lewis [00:25:31]: Who inspires you to be a better dad? Matthew Morris [00:25:33]: My wife holds me accountable for being a better dad. My daughter inspires me to be a better dad. Christopher Lewis [00:25:40]: Now you've given a bunch of pieces of advice today, things that you've learned so far. You've got more to learn as well as your daughter gets older. But as we finish up today, what's one piece of advice you'd wanna give to every dad? Matthew Morris [00:25:51]: Don't ever let your kindness be mistaken for weakness. You have now entered into a world where you have something that is precious, especially if you have a daughter. And my baby is only 6 months old and I see this with strangers. They will come up to her and she is beautiful, and cute, and bubbly, and engaging, and interacting. And the first thing they wanna do is reach out and squeeze her. That is not an acceptable course of action for anyone to attempt to physically touch my infant daughter without my express consent. Basically, if I don't give you permission to give her a hug, to grab her arm, to grab her cheek, you doing that is a violation of her personal space, and you might get smacked. If I don't get you, her mom will. Matthew Morris [00:26:50]: And as a dad, it does not matter what your culture is. It does not matter what your background is. It does not matter what other people tell you. You protect what is yours the best way that you believe it to be. And don't ever doubt yourself for doing the thing that you believe is in the best interest of your daughter. Christopher Lewis [00:27:14]: Now if people wanna find out more about you, your book, and more about what you're doing next, where's the best place for them to go? Christopher Lewis [00:28:04]: If you've enjoyed today's episode of the dads with daughters podcast, we invite you to check out the fatherhood insider. The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step roadmaps, and more, you will engage and learn with experts, but more importantly, dads like you. So check it out at fatheringtogether.org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with daughters is a program of fathering together. We look forward to having you back for another great guest next week all geared to helping you raise strong and powered daughters and be the best dad that you can be. We're all in the same boat, And it's full of tiny screaming passengers. We spend the time. We give the lessons. We make the meals. We buy them presents and bring your a game. Because those kids are growing fast. The time goes by just like a dynamite blast. Calling astronauts and firemen, carpenters, and musclemen. Get out and be the world to them.

In a recent episode of the Dads with Daughters podcast, hosted by Dr. Christopher Lewis, the special guest Markus Wolf opened up about his experiences as a father to two daughters. Markus shared valuable insights into the multi-faceted journey of fatherhood, touching on themes ranging from emotional intelligence to the importance of male connections. Here, we delve deeper into the key topics from their enlightening conversation. The Joy and Fear of Knowing You'll be a Dad The Initial Ecstasy When Markus found out he was going to be a father, the joy was immediate. "I was ecstatic," he said, reflecting on that transformative moment. Unlike some men who may be taken by surprise or even ambivalence at the prospect of fatherhood, Markus had known from a young age that he wanted to be a dad. He even felt that having daughters was a form of karmic balance, avoiding the potential rebelliousness he feared from having a son. The Inherent Fears Despite his enthusiasm, Markus admitted that the journey of fatherhood comes with its own set of anxieties. One of his biggest concerns has always been about maintaining open lines of communication. He emphasized that building a home where his daughters feel safe to express themselves emotionally is crucial, yet challenging. This desire for transparent communication stemmed from his own struggles with emotional intelligence, something he recognized needed constant work. Crafting Unique Relationships with Each Child Individual Awareness One of the critical parenting strategies Markus highlighted was the importance of recognizing the distinct personalities of each child. For example, his daughter Madison is a "fireball," prone to expressing herself loudly, while Sienna tends to close off and become quiet. Understanding these differences has allowed Markus to tailor his parenting approach, ensuring that he meets each daughter's emotional needs effectively. Skill Development Through Coaching Techniques Drawing from his career as a fitness coach, Markus has seamlessly integrated coaching principles into his parenting. He speaks of a "confidence model" where he gradually builds his daughters' skill sets in a manner that empowers them. Much like his clients who increasingly master fitness routines, his children too are slowly being endowed with various life skills. Whether it's making breakfast or picking up their toys, these seemingly mundane tasks are steps toward building a well-rounded individual. Balancing Emotions and Strengthening Connections Managing Temperaments Markus is candid about one of his personal challenges—being a bit of a "hothead." He regularly finds himself working on temper control to avoid alienating his daughters. For Markus, being in a better emotional state often involves engaging in physical activity and maintaining connections with other men. These practices help him manage stress better, creating a more harmonious home environment. The Role of Male Connections The COVID-19 pandemic brought to light an essential aspect of Markus's life—male interaction. Prior to the outbreak, he found much-needed camaraderie in his daily interactions with clients and friends. The pandemic made him realize how vital these connections were for his mental well-being. According to Markus, this communication acts as a stress-relief mechanism, enabling him to return home balanced and prepared for fatherhood duties. The Mentor and Coach Pivot Incorporating Coaching into Parenting Markus describes his approach as "Miyagi-ing" his kids, reminiscent of the lessons from "The Karate Kid." By embedding valuable life skills subtly into daily routines, he's preparing his daughters for the real world without them even realizing it. This stealth approach to skill-building enables Markus to parent effectively, ensuring his daughters are ready for life's challenges while maintaining a supportive relationship. Role Models and Inspirations He also spoke about the crucial need for every man to retain some level of selfishness, not in a negative sense, but in terms of self-care. By maintaining his own well-being, Markus not only becomes a better father but also a better role model. The "loneliness epidemic" among men is something Markus is keenly aware of, actively working to combat it through his practice of connecting with other fathers and men. The Imperfect Yet Rewarding Journey of Fatherhood Markus Wolf's journey through fatherhood is not about being perfect; it's about being present and continuously striving for improvement. He emphasizes that fatherhood is a blessing that requires a balanced approach—recognizing individual needs, maintaining personal well-being, and building strong, open relationships. Markus's story serves as a powerful reminder that fatherhood, with all its challenges, is an evolving adventure, filled with moments of joy, learning, and profound love. For more insights and advice on fatherhood, join the "Dads with Daughters" community and explore resources that could make your parenting journey a little smoother.   TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:16]: Welcome back to the Dads with Daughters podcast where we bring you guests to be active participants in your daughters' lives, raising them to be strong, independent women. Really excited to have you back again this week. Every week, I love being able to have these conversations with you where we are walking on this path together, where you and I are working to raise our daughters in the best way that we know how. And the most important thing that everyone needs to understand, no matter if you have 1 daughter, 2 daughters, 7 daughters, doesn't matter, is that we don't have to do this alone. And every week I love being able to have a conversation with you, to walk with you as we are walking down this path together, as I said, But knowing that, we don't all know everything. There is not the there is not one right way to father, and there's not one playbook to follow. So it is important for us to be able to learn from others, find other resources, find more tools for our toolbox that we can pull from to be able to be the best dads that we want to be that will help our daughters to be the women that they want to be in the future. That's why every week I bring you different guests, different people that have different experiences, that are walking this path alongside of you and are doing things maybe in a little bit different way. Dr. Christopher Lewis [00:01:38]: But that's okay because we can learn and grow from all of their experiences as well. And this week, we have another great guest with us today. Markus Wolf is with us today. And Markus is a father of 2 daughters, and I'm really excited to have him here and for him to share his experiences with us. Markus, thanks so much for being here today. Markus Wolf [00:01:56]: Thanks for having me, Chris. Dr. Christopher Lewis [00:01:57]: It is my pleasure. Love having you here today. 1st and foremost, question I always start off with. I love being able to have the power to turn the clock back in time. I know you have 2 daughters. So So I wanna go back to that first moment. That first moment that you found out that you were gonna be a dad to a daughter. What was going through your head? Markus Wolf [00:02:13]: I was ecstatic. I really was. I knew I wanted to be a dad since I was very young, which some dads never expect to have a child. Some of them never even wanted to have a child and I knew it. I knew it since I was in grade school. I was like, it was part of the vision. I'm going to be a father. So when it happened, it was just kind of I knew I was with the right woman. Markus Wolf [00:02:32]: I knew everything was just pieced together perfectly. So I was really, really excited, especially girl for some reason. I think, I was pretty tough as a son, and I just didn't want the payback that my father got. So it was kinda nice to just know that I was like, okay. Great. I only have to deal with a a daughter and then I got a second one. So that was like, okay. Never gonna deal with a son. Markus Wolf [00:02:51]: Nothing wrong with having sons, of course. Dr. Christopher Lewis [00:02:53]: So you said you always knew that you wanted to be a father. Talk to me about that. What was it about being a father that really, I'm gonna say intrigued you or made you want to be a father yourself? You know, Markus Wolf [00:03:06]: Chris, it's kinda hard to explain. Right? It just some kids grow up and they wanna be firefighters. They wanna be doctors. And then some of them fulfill that that vision. And it was just part of the process of, like, what I pictured myself. I said to myself, I wanted the white picket fence house. I wanted kids. I wanted that lifestyle. Markus Wolf [00:03:23]: So I'm not really sure how to even explain it. It was just something that I knew that I desired. Dr. Christopher Lewis [00:03:27]: I talked to a lot of different dads. A lot of different dads tell me that walking into fatherhood is a bit scary. There's some fear that goes along with being a dad. A lot of it comes back to the fact that there's no playbook to really follow that outside of the mentoring or what you've seen in your life. As you look at the experiences that you've had thus far as a father, what's been your biggest fear in raising daughters? Markus Wolf [00:03:50]: Communication is something you really want. It's one of the hardest things when it comes to parenting. And the the again, part of what I always pictured was my children were gonna always be able to come to me for support and to open up emotionally. And then I realized really quickly, and I think kids do this, relationships do this as well. They expose what you haven't been working on. And I wasn't working on my emotional intelligence. I mean, God bless my wife, Lindsay, for even, like, always just putting up with my, you know, I'm very like, you could call it passionate, but I usually just call it hot tempered. And when you have children again, they're not going to want to come to a human being who just doesn't know how to sit there and and, you know, understand where they're coming from and really be able to just not try to, you know, do the manly thing of just fixing their scenario. Markus Wolf [00:04:38]: So that's the one thing I'm always afraid of. I just want them to not feel like they're ever afraid to come to me to be, I need support with X, Y, and Z. And then, because perhaps I'm not showing the greatest of light, they don't come to me. That'd be the, the, probably the worst thing because they, I don't know. I mean, I feel like I've always valued having mentors and I don't need to be their top mentor, but I would like to be someone that could come to. Markus Wolf [00:04:59]: And I'm definitely gonna be following back up with that on the mentorship piece because I think that that's something that you are incorporating into your fatherhood and I wanna delve a little bit deeper into that. But before I do, I wanna ask you a little bit about when you raise children, it's not always easy. There are ups, downs, sideways, everything in between. And there are good days, there are bad days, there are you know what I mean. So, what has been the hardest part for you in being a father to a daughter? Markus Wolf [00:05:29]: I mean, you kind of said it. I'm very regimented. It's just the way I can handle the toughness of life, if you want to say. And things have to be put in place so perfectly. And that's not parenting. And that's even different when you have 2 different children that have different requirements, different skill sets. I've tried with one of them will work on a Monday and then it won't work on a Tuesday and it's incredibly frustrating. And then again, yeah, it's a constant roller coaster. Markus Wolf [00:05:53]: That's probably the toughest part because it would be so great if they just did exactly what I asked them to do all the time, but they don't. So it's probably that constant battle I have to have with myself to just slow it down and not desire so much. It's just, like, let it go type of thing. Dr. Christopher Lewis [00:06:11]: Now you talk just talked about the fact that what works with one child may not work with the other. And every child is is different and the personalities are different. So talk to me about what you've had to do to be able to build those unique relationships with each of your daughters that may be different from each other. Oh, I Markus Wolf [00:06:28]: mean, first, yeah, you have to almost understand what their qualities are, right? I mean, I have my oldest daughter Madison, who she's just a fireball. So she'll rather yell, she'll scream. So she'll still voice her and she'll still communicate with words. And then you obviously have to, you know, deal with that. You just have to try to, like, bring the person bring Madison down a little bit. With my other daughter, Sienna, she just closes off. Like, she doesn't use words. She gets really quiet. Markus Wolf [00:06:52]: So then you're always just trying to figure out, well, now I know that this one is up and you gotta bring this one down to balance and the other one's a little bit down and you gotta bring it down. So that's been the first one. It's just being aware of how they respond to certain type of emotions. And then when you understand it, then you're like, okay, cool. Now what do I have in my tool belt to to bring one down and bring the other one up? Dr. Christopher Lewis [00:07:12]: Now you talked about that sometimes you can be a little bit of a hothead and you have to temper that. As you said, you don't want your children to be afraid to come to you because of that. How have you had to work on that to be able to get to a point where either you're in the right space or that you've had to had those conversations with your daughters, and you might not have had to have them yet with them so that they understand. But how have you been able to realign yourself in being a father and knowing that your emotions may be a little bit more heated and you have to be able to adjust for that. Markus Wolf [00:07:50]: I'm in fitness. I'm in health. And for me, I believe it's always about putting yourself into like a better state. So if you're like energetic, the stress is relieved. So usually, I think most dads can agree that the milk spilled on the floor is not why you had this huge yelling outburst or the TV not being shut off when you asked for it to be shut off is not really why you're you're yelling. Because if you really put things into perspective, you're like, okay. Am I really gonna get mad at this at a child for not shutting off the TV? Or am I mad because there's a whole bunch of other things I'm incredibly stressed out about that I hadn't just, you know, worked through. So for me, I have to always put myself into a state. Markus Wolf [00:08:26]: And one of them that I've really worked on for the last 2 years is I have to have a male connection at least once a week. That is like a mandatory and it's worked fabulously because once I do it, I come back and I'm I could recognize myself being like, oh, okay. So I think it was just because I needed a little bit of like stress relief. So I mean, obviously stress stress relief can look different for so many other men, but that has been the one that just brings me to the state that I need to be for parenting, if that makes sense. Dr. Christopher Lewis [00:08:52]: It does. And now you talked about the fact that you are a mentor, but you're also a coach. You are and you're incorporating some of those things that you've been doing in your own business as a fitness coach, as a coach in general into your parenting. So talk to me about how you've been able to pivot that in being able to do what you're doing with clients and trying to incorporate that into the work that you're doing in trying to be the father that you want to be? Markus Wolf [00:09:29]: I stumbled upon this. It must have been just almost like an epiphany. I was just obviously I was coaching a lot of men and parenting every single day. And then I started to realize there's something there where the ultimate goal, I believe this is my parent and style. I don't know if this is all fathers is my job is to set them up for the world, right? And the more skill sets I give them, the more, like, you know, let's say even like the emotional intelligence skills around the house. All these like little things are foundational tools that you do for clients. Like clients, they need to have foundational tools to get food prepared so they could eat healthier meals. They could go outside and prioritize themselves. Markus Wolf [00:10:08]: So there's there's very much I tried to work in. What is the process number 1 for this child? I mean, where are we at? Like, you know, at 3 years old, they could barely pick up many things. But at 4 years old, they can empty the dishes. At 5 years old, they can make their own breakfast, things like that. So I started to realize that my coaching style was always like that. It's kind of like a, I call it the confidence model where you take someone and you just, what is the one thing that could boost their confidence? But it's a very easy thing that they can do. And then each time you have to recognize what is the next thing they need to do to again move towards those skill sets that you were speaking of. So I've been doing it with my children. Markus Wolf [00:10:42]: They're excellent at things around the house now without realizing that it wasn't, I'm asking, like, you know, it's not doesn't feel like a chore, I guess, I suppose you're saying. Because, again, I'm gonna use this great reference because I've been watching Cobra Kai for those past couple weeks, which is I Miyagi then. You know, it's mean I just and I do that with my clients. I Miyagi them to just suddenly have these skill sets and now they're like, oh my goodness. Now I'm like equipped for the world and I'm like, yes. I did what I needed to do. Dr. Christopher Lewis [00:11:05]: Now even in Cobra Kai and Karate Kid, Daniel san ends up figuring out that he's getting Miyagi ed. So your kids are going to figure it out sometime. And they're probably going to be like, what the heck, dad? Why are you doing this? How are you gonna react? Markus Wolf [00:11:19]: I might even just do what I just did right now. I might smile a little and just said, you know, this is this is what I'm I'm trying my best. I'm like, I'm trying my best. I have good intentions and I think sometimes that's, like, at least gives you half the pass. But, yeah, if I get exposed, I will get back to you and I'll let you know how I handle it. Dr. Christopher Lewis [00:11:34]: So talk to me about you talked earlier about the fact that you found within your own life that you need to have those connections with other men, other fathers, other individuals, so important for you. I don't like referencing COVID too much, just because there's, so important for you. Markus Wolf [00:11:55]: I don't like referencing covid too much just because this feels like something you just want to put behind you. But it made me recognize that what I had in the past was like a third home. I had a place to go out and when I would personal trained before covid, I was interacting with 5, 10 people a day. And then when you go from 5, 10 to 0, you start to realize that that was something that was a requirement for you. You like being heard, you like hearing other people's stories. And then when you eliminate that, I started to replace my wife for that. So really, it was just get back that same outlets. And then then again, I I can't explain why it feels so good, but it was it was exactly what I just needed. Markus Wolf [00:12:32]: I just need to talk to others and hear others and just get out and about. Dr. Christopher Lewis [00:12:35]: You know, I've come to find that some men are for some men, that is not an easy thing to do, to reconnect, to make those connections, to make those friendships, especially once we become adults. Don't seem to have problems usually when we're growing up. We make those connections. We have friendships. But as we get into our adulthood and we start focusing on family, profession, other things, the push for maintaining friendships, building friendships goes away. As someone that mentors others, that coaches others, why do you think that happens? And what have you done to be able to try to help other men to reconnect like you are? Markus Wolf [00:13:16]: That's a really great point. You made me remember what it was like being with my father or being raised with my father and he had 0 friends. So I think that was already a glaring sign. And the first things that I feel like I recognize was I talk about that a lot with clients, even sometimes the very first interaction. I say to them that when we were younger, when we were men, it was 95% of our time were with other men. Locker room banter, playing video games, going outside, and you're pretty much just hanging out with men your whole entire life up until the point when you're dating the person that you're eventually gonna have children with and then get married. So for me, I personally just started to use I'm a meathead at heart, Chris, to be honest. So I just work out with men because it just seems to be a 2 birds with 1 stone type of scenario. Markus Wolf [00:14:05]: And I think a lot of men can can connect with that. Maybe it's not working out. Maybe it's, hey. I'm gonna go join a softball team, and that might even just be enough to do the thing. Markus Wolf [00:14:14]: No, it does. And I think that it's important to understand that. That's one of the reasons why in fathering together, we develop the online communities that we have, but we also have in person opportunities for dads to connect with other dads and be able to open up opportunities for men to be able to connect, connect with their kids, connect with each other because connection is so important. But we, as I said, sometimes forget about that and focus so much on other aspects that leads to the prevalence of loneliness. And you'll see lots of studies that are out there right now that talk about the pervasiveness of loneliness in malehood right now. And most men don't wanna talk about it, and they just wanna kind of push it down and keep pushing forward because that's what we do. We push through, right? So it's not an easy thing to deal with, but it's also important to for us to deal with because if we don't, our kids are watching and our kids will also identify and see what's happening. So one of the questions that I have, I guess, is this because you work with a lot of dads and men in the coaching that you do through fitness, through life. Dr. Christopher Lewis [00:15:32]: What are some of the biggest challenges that some of these men that are coming to you, working with you right now are dealing with? And are you seeing commonalities amongst them? Markus Wolf [00:15:41]: 100%. I feel like at this point, because I've worked with 100 and it's just patterns. And usually the one pattern that I'm noticing a lot is the values they have are outside of themselves. So it's never a bad thing to provide. That's one of a very important role you're supposed to do as a parent, as an adult. But I couldn't understand that because I'll admit it, I was quite selfish in my twenties, which kind of prepared me for how to, you know, be successful in fitness. But their line in what it does, it prioritizes self, it prioritizes if your energy is not where you want it to be, you prioritize it. If your stress management is not where you want it to be, you prioritize it. Markus Wolf [00:16:21]: And most of the men I work with, and this is what I fear for my kids, is, like, they don't prioritize themselves. They prioritize appeasing work, their boss, wife. You gotta keep your wife happy, but she's in control of her own happiness. In my personal opinion, that if you're not in control of yours, that's probably a big, big issue. Dr. Christopher Lewis [00:16:40]: For those men that you're working with that have a hard time identifying those priorities, because sometimes men do. Sometimes they are floundering a bit and there are individuals that are listening right now that may be thinking, I just don't know where to start. Where should they start? Markus Wolf [00:16:55]: Using that same model that I spoke about, it's usually the easiest route is the first route. So even if it's just going for a walk and listening to an audiobook you've been wanting to listen to forever, It's probably a larger sense of accomplishment to some men than you would even believe. To others, it would be that's just a typical Monday morning. I go for a walk on the beach and I listen to an audiobook or something. But for them, some of these men, they they they just keep saying that they're going to do something. And that's that action, I believe, is already enough for them to, put forward towards where they need to go. And if you're already doing that again, what is the the thing that you keep holding off at? Because that's likely the thing that's gonna push you forward. Dr. Christopher Lewis [00:17:33]: I appreciate you sharing that as well. Now, we always finish our interviews with what I like to call our fatherhood 5 where I ask you 5 more questions to delve deeper into you as a dad. Are you ready? Ready. In one word, what is fatherhood? Markus Wolf [00:17:43]: It's a blessing. Dr. Christopher Lewis [00:17:43]: When was the time that you finally felt like you succeeded at being a father to a daughter? Markus Wolf [00:17:47]: I take my girls on a on a monthly date. And usually, on days where they finish school, you have to drag them out of the playground just to leave to go home. But on our monthly dates, they will run and they cannot wait to to join me. And I feel like that's they're looking forward to it. That's already a good sign. Dr. Christopher Lewis [00:18:03]: Now your kids are still young, so they might not have a lot of answers for this. But if I was to talk to your kids, how would they describe you as a dad? Markus Wolf [00:18:09]: I think they totally answer it with, I'm the fun guy who tends to yell a lot. Dr. Christopher Lewis [00:18:14]: Now let's go at this point maybe 15 years down the road. What do you want them to say then? Markus Wolf [00:18:19]: As long as they could say something, that's the man I trust, That's the man I I look up to. That's the man that I am looking to get him a partner like. Dr. Christopher Lewis [00:18:26]: Who inspires you to be a better dad? Markus Wolf [00:18:27]: Ben, 100%. Dr. Christopher Lewis [00:18:28]: Now you've given a lot of piece of advice today, things that you've learned along the way. What's one piece of advice you'd wanna give to every dad? Markus Wolf [00:18:34]: Choose your battles. If you're like me, you want like, I just told you, I I wanna add skill sets to them. I want them to have things to be better in the world, but it's not gonna happen overnight. So just sometimes let it go. Dr. Christopher Lewis [00:18:46]: And that's definitely not always easy. Markus Wolf [00:18:48]: No. It's probably the toughest thing I've ever done in my life. Dr. Christopher Lewis [00:18:51]: Now, if people wanna find out more about you and what you're up to, where should they go? Markus Wolf [00:18:55]: They can find me on Instagram, coach Markus Wolf, m a r k u s, Wolf, and drop a whole bunch of knowledge bombs if they want anything. And also just, again, resonance. So if you're a father and you're just looking to resonate with someone who's been holding on to healthy habits even with 2 children, just give me a call. Dr. Christopher Lewis [00:19:10]: Well, Markus, I just wanna say thank you. Thank you for being here today, for sharing what you've learned thus far, and I wish you all the best. Markus Wolf [00:19:17]: Appreciate you, Chris. This was a pleasure. Dr. Christopher Lewis [00:19:19]: If you've enjoyed today's episode of the dads with daughters podcast, we invite you to check out the fatherhood insider. The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step roadmaps, and more, you will engage and learn with experts, but more importantly dads like you. So check it out at fatheringtogether.org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with daughters is a program of fathering together. We look forward to having you back for another great guest next week all geared to helping you raise strong and powered daughters and be the best dad that you can be. Dr. Christopher Lewis [00:20:17]: We're all in the same boat, And it's full of tiny screaming passengers. We spend the time, we give the lessons, we make the meals, we buy them presents and bring your a game. Because those kids are growing fast, the time goes by just like a dynamite blast, be the best dad you can be. Be the best dad you can be.

Dr. Linda Duska and Dr. Domenica Lorusso discuss the practice-changing results of the phase 3 ENGOT-cx11/GOG-3047/KEYNOTE-A18 study, which evaluated pembrolizumab plus chemoradiotherapy as treatment for previously untreated, high-risk, locally advanced cervical cancer. TRANSCRIPT  Dr. Linda Duska: Hello, I'm Linda Duska, your guest host of the ASCO Daily News Podcast today. I'm a professor of obstetrics and gynecology and serve as the associate dean for clinical research at the University of Virginia School of Medicine. On today's episode, we'll be discussing a new standard of care for previously untreated, high- risk locally advanced cervical cancer. This follows the ENGOT-cx11/GOG-3047/KEYNOTE-A18 study, which I will be referring to as KEYNOTE-A18 for the rest of this podcast, which demonstrated that pembrolizumab plus chemoradiotherapy improved both progression-free and overall survival compared to chemoradiotherapy alone. I was a co-author of this study, and I'm delighted to be joined today by the study's lead investigator, Dr. Domenica Lorusso, for today's discussion. She is also a professor of obstetrics and gynecology. She's at Humanitas University Rosano and the director of the Gynecologic Oncology Unit at the Humanitas Hospital San Pio in Milan, Italy. Our full disclosures are available in the transcript of this episode. Dr. Lorusso, it's great to be speaking with you today. Dr. Domenica Lorusso: Thank you, Linda. It's a great pleasure to be here. Thank you. Dr. Linda Duska: So I was hoping you could start us out with some context on the challenges associated with treating patients with high-risk, locally advanced cervical cancer. Dr. Domenica Lorusso: Yes. I have to make a disclosure because in my experience as a gynecologist, cervical cancer patients are the most difficult patients to treat. This is a tumor that involves young patients [who often have] small kids. This is a very symptomatic tumor. More than 50% of patients report pain. Sometimes the pain is difficult to control because there is an infiltration of the pelvic nerves and also a kind of vaginal discharge, so it's very difficult to treat the tumor. Since more than 25 years, we have the publication of 5 randomized trials that demonstrate that when we combine platinum chemotherapy to radiation treatment, we increase overall survival by 6%. This is the new standard of care – concurrent chemoradiation plus brachytherapy. This is a good standard of care because particularly modern, image-guided radiotherapy has reported to increase local control. And local control in cervical cancer translates to better overall survival. So modern radiotherapy actually is able to cure about 75% of patients. This is what we expect with chemoradiation right now. Dr. Linda Duska: So what are the key takeaways of A18? This is a really exciting trial, and you've presented it a couple of times. Tell us what are the key takeaways that you want our listeners to know. Dr. Domenica Lorusso: Linda, this is our trial. This is a trial that we did together. And you gave me the inspiration because you were running a randomized phase 2 trial exploring if the combination of pembrolizumab to concurrent chemoradiation was able to give signals of efficacy, but also was feasible in terms of toxicity. There were several clinical data suggesting that when we combine immunotherapy to radiotherapy, we can potentially increase the benefit of radiotherapy because there is a kind of synergistic effect between the two strategies. Radiotherapy works as a primer and immunotherapy works better. And you demonstrated that it was feasible to combine immunotherapy to concurrent chemoradiation. And KEYNOTE-A18 was based on this preliminary data. We randomized about 1,060 patients to receive concurrent chemoradiation and brachytherapy or concurrent chemoradiation and brachytherapy in combination with pembrolizumab followed by pembrolizumab for about two years. Why two years? Because in more than 80% of cases, recurrence in this patient population occurred during the first two years. So the duration of treatment was based on the idea to provide protection to the patient during the maximum time of risk. And the trial had the two primary endpoints, progression free and overall survival, and met both the endpoints, a significant 30% reduction in the risk of progression that was confirmed. At the 3-year follow up, the observation was even better, 0.68. So 32% reduction in the risk of progression. And more importantly, because this is a curative setting, 33% reduction in the risk of death was reported in the experimental arm when pembro was combined with chemoradiation. Dr. Linda Duska: That's amazing. I wanted to ask you, a prior similar study called CALLA was negative. Why do you think A18 was positive? Dr. Domenica Lorusso: Linda, there are several discussions about that. I had the possibility to discuss several times with the PI of CALLA, Brad Monk. The idea of Brad is that CALLA was negative because of using durvalumab instead of PD-1 inhibitor, which is pembrolizumab. I do not have exactly the same impression. My idea is that it's the kind of patient population enrolled. The patient population enrolled in KEYNOTE-A18 was really a high-risk population; 85% of that patient were node positive, where the definition of node positivity was at least 2 lymph nodes in the pelvis with a short diameter of 1.5. So, we are very confident this patient was node-positive, 55% at the grade 3 and 4 diseases. So this is really a high-risk population. I remember at the first presentation of CALLA, I was honored to discuss the CALLA trial when it was first presented at IGCS a few years ago. And when I received the forest plot of Calla, it was evident to me that in patients with stage III and node positive there was a signal of efficacy. And we have a huge number of patients with node positive. So in my opinion this is the reason why KEYNOTE-A18 is positive. Dr. Linda Duska: Yeah, I agree with you. I've thought about it a lot and I think you're right about that. The INTERLACE trial results were recently published. How should we interpret these results in the context of A18? Dr. Domenica Lorusso: So it's very difficult to compare the 2 trials. First of all, in terms of population. The population enrolled in INTERLACE is a low-risk, locally advanced but low risk population; 76% were stage II, 10% were stage I, 60% were node-negative patients. So, first of all, the population is completely different. Second is the type of radiotherapy that was provided. INTERLACE is a 10-year long trial, but in 10 years the quality and the technique of radiotherapy completely changed. Only 30% of patients in INTERLACE received what we call the modern image-guided brachytherapy, which is important because it provides local control and local control increases overall survival. And third, we read the paper. I'm not a methodologist, but there are some methodological biases in the paper. All the statistical design of the trial was based on PFS, but PFS was evaluated at physician description. And honestly, I never saw a trial that had no pre-specified timeline for radiological evaluation. It's very difficult to evaluate progression in cervical cancer because the fibrosis related to radiotherapy changes the anatomy in the pelvis. And I think that the radiological evaluation is important to address if the patient is progressing or not. Particularly, because the conclusion of CALLA is that the PFS was mainly in favor of distant metastasis. So really, it's difficult for me to understand how distant metastasis may be evaluated with the vagina visit. So really, it's very difficult to compare the two trials, but I have some concerns. And also because of toxicity in the study, unfortunately 30% of patients did not complete concurrent chemoradiation because of residual toxicity due to induction chemotherapy. So I wanted to be sure in the context of modern radiotherapy, if really induction chemo adds something to modern radiotherapy. Dr. Linda Duska: Well, I have two more questions for you. As we move immunotherapy into the front line, at least for these high risk locally advanced cervical cancer patients that were eligible for A18, what does that mean then for hopefully those few that develop recurrence in terms of second line therapy? Dr. Domenica Lorusso: Well, Linda, this is a very important question. We do not have data about immuno after immuno, but I would not completely exclude this hypothesis because in KEYNOTE-A18, the patient received treatment for a well-defined time period. And for those patients not progressing during immunotherapy, I really guess if there is a space for the reintroduction of immunotherapy at the time of recurrence. In this moment we have 30% of patients in KEYNOTE-A18 in the control arm that receive immunotherapy after progression, but still we have 11% of patients that receive immunotherapy in combination with concurrent chemoradiation and then receive, again, immunotherapy in later line of therapy. I think we need to collect these data to capture some signals and for sure we have the new drug. We have antibody drug conjugate. The trials are ongoing exploring the role of antibody drug conjugate, particularly in immune pretreated patients. So I think this is a very interesting strategy. Dr. Linda Duska: I was going to ask you, “What are the next steps,” but I think you already answered that question. You talked about the second line. If you were going to redesign a study in the frontline, what would it look like? Dr. Domenica Lorusso: Probably one question that I would like to answer – there are two questions in my opinion in KEYNOTE-A18 – one is induction immunotherapy. Linda, correct me if I'm wrong, you reported very interesting data about the immune landscape change when you use induction immunotherapy. And I think this is something that we need to explore in the future. And the second question is the duration of maintenance. Because, again, we decided for two years based only on the epidemiology of recurrence, but I guess if one year may be enough. Dr. Linda Duska: I think this sequencing question is really important, that the induction immunotherapy was actually GY017. I can't take credit for that, but I think you're right. I think the sequencing question is really important. Whether you need the concurrent IO or not is an important question. And then to your point about the 2 years, the length of the need for maintenance therapy is a question that we don't know the answer to. So there are lots of really important questions we can continue to ask. I want to thank you so much for sharing your valuable insights with us on the podcast today. You're always so thoughtful about this particular study and cervix cancer in general and also for your great work to advance the care for patients with GYN cancers. Dr. Domenica Lorusso: Thank you, Linda. It's our work - we progress together. Dr. Linda Duska: Yes. And we thank the patients as well. The over 1,000 patients that went on this trial during a pandemic. Right? Dr. Domenica Lorusso: Absolutely. Without their generosity and their trust, we would not be able to do this trial. Dr. Linda Duska: So we're very grateful to them and we thank 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. Thank you all.   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. Linda Duska @Lduska Dr. Domenica Lorusso   Follow ASCO on social media:   @ASCO on Twitter   ASCO on Facebook   ASCO on LinkedIn     Disclosures:   Dr. Linda Duska: Consulting or Advisory Role: Regeneron, Inovio Pharmaceuticals, Merck, Ellipses Pharma Research Funding (Inst.): GlaxoSmithKline, Millenium, Bristol-Myers Squibb, Aeterna Zentaris, Novartis, Abbvie, Tesaro, Cerulean Pharma, Aduro Biotech, Advaxis, Ludwig Institute for Cancer Research, Leap Therapeutics Patents, Royalties, Other Intellectual Property: UptToDate, Editor, British Journal of Ob/Gyn Dr. Domenica Lorusso: Consulting or Advisory Role: PharmaMar, AstraZeneca, Clovis Oncology, GSK, MSD, Genmab, Seagen, Immunogen, Oncoinvest, Corcept, Sutro Biopharma, Novartis, Novocure, Daiichi Sankyo/Lilly Speakers' Bureau: AstraZeneca, Clovis, GSK, MSD, ImmunoGen, Seagen Research Funding (Inst.): PharmMar, Clovis, GSK, MSD, AstraZeneca, Clovis Oncology, Genmab, Seagen, Immunogen, Incyte, Roche, Pharma&, Corcept Therapeutics, Alkermes Travel, Accommodations, Expenses: AstraZeneca, Clovis, GSK, Menarini  

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.      

Dr. Ryan Augustin and Dr. Jason Luke discuss neoadjuvant immunotherapy and the importance of multidisciplinary team coordination, promising new TIL therapy for advanced melanoma, and the emerging role of CD3 engagers in treatment strategies. TRANSCRIPT Dr. Ryan Augustin: Hello, I'm Dr. Ryan Augustin, your guest host of the ASCO Daily News Podcast today. I'm a medical oncology fellow at Mayo Clinic in Rochester, Minnesota. Joining me today is Dr. Jason Luke, an associate professor of medicine and the director of the Cancer Immunotherapeutic Center at the University of Pittsburgh Hillman Cancer Center. I had the privilege of working as a postdoc in Jason's translational bioinformatics lab, where we investigated mechanisms of resistance to immunotherapy in melanoma and other cancers.  Today, we'll be discussing 3 important topics, including neoadjuvant immunotherapy and the importance of multidisciplinary team coordination, the impact and practical considerations for incorporating TIL therapy into melanoma, and the current and future use of CD3 engagers in both uveal and cutaneous melanoma.  You'll find our full disclosures in the transcript of this episode.  Jason, it's great to have this opportunity to speak with you today. Dr. Jason Luke: Absolutely. Thanks, Ryan. It's great to see you. Dr. Ryan Augustin: So, to kick things off, Jason, we, of course, have seen tremendous advances in cancer immunotherapy, not only in metastatic disease but also the perioperative setting. Recent data have shown that the use of neoadjuvant therapy can provide not only critical prognostic information but can also help individualize post-resection treatment strategies and potentially even eliminate adjuvant therapy altogether in patients who achieve a pathologic, complete response. This signifies a conceptual shift in oncology with the goal of curing patients with immunotherapy. In triple-negative breast cancer, the KEYNOTE-522 regimen with pembrolizumab is standard of care. In non-small cell lung cancer, there are now four FDA approved chemo-IO regimens in both the neoadjuvant and perioperative settings. And, of course, in melanoma, starting with SWOG S1801 utilizing pembro mono therapy, and now with combined CTLA-4 PD-1 blockade based on results from the NADINA trial, neoadjuvant IO is the new standard of care in high-risk, resectable melanoma. It's important to highlight this because whereas other tumor types have more mature multidisciplinary care, for example, patients with breast cancer are reviewed by the whole team in every center, and every patient with lung cancer certainly benefits from multidisciplinary care conferences, that's not always the case with melanoma, given the relative frequency of cases compared to other tumor types.  Jason, would you say that we have now moved into an era where the integration of a multidisciplinary team and melanoma needs to be prioritized. And why is it important to have multidisciplinary team coordination from the onset of a patient's diagnosis? Dr. Jason Luke: Well, I think those are great questions, Ryan, and I think they really speak to the movement in our field and the great success that we've had integrating systemic therapy, particularly immunotherapy, into our treatment paradigms. And so, before answering your question directly, I would add even a little bit more color, which is to note that over the last few years, we've additionally seen the development of adjuvant therapy into stages of melanoma that, historically speaking, were considered low-risk, and medical oncologists might not even see the patient. To that, I'm speaking specifically about the stage 2B and 2C approvals for adjuvant anti-PD-1 with pembrolizumab or nivolumab. So this has been an emerging complication.  Classically, patients are diagnosed with melanoma by either their primary care doctor or a dermatologist. Again, classically, the next step was referral to a surgeon who had removed the primary lesion, with discussion around nodal evaluation as well. And that paradigm has really changed now, where I think integration of medical oncology input early on in the evaluation of the appropriate treatment plan for patients with melanoma is quite a pressing issue now, both because we have FDA approvals for therapeutics that can reduce risk of recurrence, and whether or not to pursue those makes a big difference to the patient for discussion early on.  And, moreover, the use of systemic therapies now, prior to surgery, of course, then, of course, requires the involvement of medical oncology. And just for an emphasis point on this, it's classically the case, for good reason, that surgeons complete their surgery and then feel confident to tell the patient, “Well, we got it all, and you're just in really good shape.” And while I understand where that's coming from, that often leaves aside the risk of recurrence. So you can have the most perfect surgery in the world and yet still be at very high risk of recurrence. And so it's commonly the case that we get patients referred to us after surgery who think they're just in totally good shape, quite surprised to find out that, in fact, they might have a 20% to 50% risk of recurrence. And so that's where this multidisciplinary integration for patient management really does make a big difference.  And so I would really emphasize the point you were making before, which is that we need multidisciplinary teams of med onc with derm, with surgery early on, to discuss “What are the treatment plans going to be for patients?” And that's true for neoadjuvant therapy, so, for palpable stage 3, where we might give checkpoint inhibitors or combinations before surgery. But it's true even in any reasonably high-risk melanoma, and I would argue in that state, anything more than stage 1 should be discussed as a group, because that communication strategy with the patient is so important from first principles, so that they have an expectation of what it's going to look like as they are followed out over time. And so we're emphasizing this point because I think it's mostly the case at most hospitals that there isn't a cutaneous oncology disease management meeting, and I think there needs to be.  It's important to point out that usually the surgeons that do this kind of surgery are actually either the GI surgeons who do colon cancer or the breast surgeons. And so, given that melanoma, it's not the most common kind of cancer, it could easily be integrated into the existing disease review groups to review these cases. And I think that's the point we really want to emphasize now. I think we're not going to belabor the data so much, but there are enormous advantages to either perioperative or adjuvant systemic therapy in melanoma. We're talking about risk reduction of more than 50%, 50-75% risk reduction. It's essential that we make sure we optimally offer that to patients. And, of course, patients will choose what they think is best for their care. But we need to message to them in a way that they can understand what the risks and benefits of those treatments are and then are well set up to understand what that treatment might look like and what their expectations would be out over time.  So I think this is a great art of medicine place to start. Instead of belaboring just the details of the trial to say, let's think about how we take care of our patients and how we communicate with them on first principles so that we can make the most out of the treatments that we do have available. Dr. Ryan Augustin: That's great, Jason. Very insightful points. Thank you.  So, shifting gears now, I'd also like to ask you a little bit about TIL therapy in melanoma. So our listeners will be aware that TIL is a promising new approach for treating advanced melanoma and leverages the power of a patient's cytotoxic T cells to attack cancer cells. While we've known about the potential of this therapy for some time, based on pioneering work at the NCI, this therapy is now FDA approved under the brand AMTAGVI (Lifileucel) from Iovance Biotherapeutics, making it the first cellular therapy to be approved for a solid tumor. Now, I know TIL therapy has been administered at your institution, Jason, for several years now, under trial status primarily for uveal melanoma using an in-house processing. But for many cancer centers, the only experience with cellular therapy has come under the domain of malignant hematology with CAR T administration. At our institution, for example, we have only recently started administering TIL therapy for melanoma, which has required a tremendous multidisciplinary effort among outpatient oncology, critical care, and an inpatient hematology service that has expertise in cytokine release syndrome.  Jason, where do you see TIL therapy fitting into the metastatic space? Which patients do you think are truly candidates for this intensive therapy? And what other practical or logistical considerations do you think we should keep in mind moving forward? Dr. Jason Luke: Well, thanks for raising this. I think the approval of lifileucel, which is the scientific name for the TIL product that's on the market now. It really is a shift, a landscape shift in oncology, and we're starting in melanoma again, as seems to be commonly the case in drug development. But it's really important to understand that this is a conceptually different kind of treatment, and therefore, it does require different considerations. Starting first with data and then actualization, maybe secondarily, when we see across the accelerated approval package that led to this being available, we quote patients that the response rate is likely in the range of 30%, maybe slightly lower than that, but a meaningful 25% to 30% response rate, and that most of those patients that do have response, it seems to be quite durable, meaning patients have been followed up to four years, and almost all the responders are still in response. And that's a really powerful thing to be able to tell a patient, particularly if the patient has already proceeded through multiple lines of prior standard therapy. So this is a very, very promising therapy.  Now, it is a complicated therapy as well. And so you highlighted that to do this, you have to have a tumor that's amenable for resection, a multidisciplinary team that has done a surgery to remove the tumor, sent it off to the company. They then need to process the TIL out of the tumor and then build them up into a personalized cell product, bring it back, you have to lympho-deplete the patient, re-introduce this TIL. So this is a process that, in the standard of care setting under best circumstances, takes roughly six weeks. So how to get that done in a timely fashion, I think, is evolving within our paradigms. But I think it is very important for people who practice in settings where this isn't already available to realize that referring patients for this should be a strong consideration. And thinking about how you could build your multidisciplinary team in a way to be able to facilitate this process, I think is going to be important, because this concept of TIL is relevant to other solid tumors as well. It's not approved yet in others, but we kind of assume eventually it probably will be. And so I think, thinking through this, how could it work, how do you refer patients is very important.  Now, coming back to the science, who should we treat with this? Well, of course, it's now an air quotes “standard of care option”, so really it ought to be available to anybody. I will note that currently, the capacity across the country to make these products is not really adequate to treat all the patients that we'd want. But who would we optimally want to treat, of course, would be people who have retained a good performance status after first line therapy, people who have tumors that are easily removable and who have not manifested a really rapid disease progression course, because then, of course, that six-week timeline probably doesn't make sense. The other really interesting data point out of the clinical trials so far is it has looked like the patients who got the least amount of benefit from anti-PD-1 immunotherapy, in other words, who progressed immediately without any kind of sustained response, those patients seem to have the best response to TILs, and that's actually sort of a great biomarker. So, this drug works the best for the population of patients where checkpoint inhibitors were not effective. And so as you think about who those patients might be in your practice, as you're listening, I think prioritizing it for primary progression on anti PD-1, again and giving it ahead thought about how would you get the patient through this process or referred to this process very quickly is really important because that lag time is a problem. Patients who have melanoma tend to progress reasonably quickly, and six weeks can be a long time in melanoma land. So, thinking ahead and building those processes is going to be important moving into the future Dr. Ryan Augustin: Definitely appreciate those practical considerations. Jason, thank you.  Moving on to our final topic, I was hoping to discuss the use of immune cell engagers in melanoma. So, similar to CAR T therapy, bispecific T-cell engagers, or BiTEs, as they're commonly known, are standard of care in refractory myeloma and lymphoma. But these antibodies engaging CD-3 on T cells and a tumor specific antigen on cancer cells are relatively new in the solid tumor space. Tarlatamab, which is a DLL-3 and CD-3 bispecific antibody, was recently approved in refractory small cell lung cancer, and, of course, tebentafusp, an HLA-directed CD-3 T cell engager was approved in uveal melanoma in 2022. Both T and NK cell engaging therapies are now offering hope in cancers where there has historically been little to offer. However, similar to our discussion with TIL therapy, bispecifics can lead to CRS and neurotoxicity, which require considerable logistical support and care coordination.  Jason, I was wondering if you could briefly discuss the current landscape of immune cell engagers in melanoma and how soon we may see these therapies enter the treatment paradigm for cutaneous disease. Dr. Jason Luke: I think it is an exciting, novel treatment strategy that I think we will only see emerge more and more. You alluded to the approval of tebentafusp in uveal melanoma, and those trials were, over the course of a decade, where those of us in solid tumor land learned how to manage cytokine release syndrome or the impact of these C3 bispecifics, in a way that we weren't used to. And what I'll caution people is that CRS, as this term, it sounds very scary because people have heard of patients that, of course, had difficult outcomes and hematological malignancies, but it's a spectrum of side effects. And so, when we think about tebentafusp, which is the approved molecule, really what we see is a lot of rash because GP100, the other tumor antigen target, is in the skin. So, patients get a rash, and then people do get fevers, but it's pretty rare to get more than that. So really what you have to have is the capacity to monitor patients for 12 hours, but it's really not more scary than that. So it really just requires treating a few people to kind of get used to these kinds of symptoms, because they're not the full-on ICU level CRS that we see with, say, CAR T-cells.  But where is the field going? Well, there's a second CD3 bispecific called brenetafusp that targets the molecule PRAME, that's in a phase 3 clinical trial now for frontline cutaneous melanoma. And tebentafusp is also being evaluated in cutaneous melanoma for refractory disease. So, it's very possible that these could be very commonly used for cutaneous melanoma, moving into, say, a two-to-four-year time horizon. And so therefore, getting used to what are these side effects, how do you manage them in an ambulatory practice for solid tumor, etc., is going to be something everyone's going to have to learn how to deal with, but I don't think it should be something that people should be afraid of.  One thing that we've seen with these molecules so far is that their kinetics of treatment effect do look slightly different than what we see with more classic oncology therapies. These drugs have a long-term benefit but doesn't always manifest as disease regression. So, we commonly see patients will have stable disease, meaning their tumor stops growing, but we don't see that it shrank a lot, but that can turn into a very meaningful long-term benefit. So that's something that we're also, as a community, going to have to get used to. It may not be the case we see tumors shrink dramatically upfront, but rather we can actually follow people with good quality- of-life over a longer period of time.  Where is the field going? You mentioned tarlatamab in small cell lung cancer, and I think we're only going to see more of these as appropriate tumor antigens are identified in different tumors. And then the other piece is these CD3 engagers generally rely upon some kind of engagement with a T cell, whether CD3 engagers, and so they can be TCR or T-cell receptor-based therapies, although they can be also SCFV-based. But that then requires new biomarkers, because TCR therapy requires HLA restriction. So, understanding that now we're going to need to profile patients based on their germline in addition to the genomics of the tumor. And those two things are separate. But I would argue at this point, basically everybody with cutaneous melanoma should be being profiled for HLA-A(*)0201, which is the major T-cell receptor HLA haplotype that we would be looking for, because whether or not you can get access immediately to tebentafusp, but therefore clinical trials will become more and more important.  Finally, in that T-cell receptor vein, there are also T cell receptor-transduced T cells, which are also becoming of relevance in the oncology community and people listening will be aware in synovial sarcoma of the first approval for a TCR-transduced T cell with afamitresgene autoleucel. And in melanoma, we similarly have TCR-transduced T cells that are coming forward in clinical trials into phase 3, the IMA203 PRAME-directed molecule particularly. And leveraging our prior conversation about TILs, we're going to have more and more cellular based therapies coming forward, which is going to make it important to understand what are the biomarkers that go with those, what are the side effect profiles of these, and how do you build your practice in a way that you can optimally get your patients access to all of these different treatments, because it will become more logistically complicated, kind of as more of these therapies come online over the next, like we said, two to four years kind of time horizon. So, it's very exciting, but there is more to do, both logistically and scientifically. Dr. Ryan Augustin: That's excellent. Thanks, Jason, and thank you so much for sharing your great insight with us today on the ASCO Daily News Podcast. Dr. Jason Luke: Thanks so much for the opportunity. Dr. Ryan Augustin: And thank you to our listeners for your time today. You will find links to the abstracts discussed today in the transcript of this episode, and you can follow Dr. Luke on X, formerly known as Twitter, @jasonlukemd. And you can find me, @RyanAugustinMD. 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.   Follow today's speakers: @ryanaugustinmd Dr. Jason Luke @jasonlukemd   Follow ASCO on social media: @ASCO on Twitter ASCO on Facebook ASCO on LinkedIn   Disclosures: Dr. Ryan Augustin: No relationships to disclose Dr. Jason Luke: Stock and Other Ownership Interests: Actym Therapeutics, Mavu Pharmaceutical, Pyxis, Alphamab Oncology, Tempest Therapeutics, Kanaph Therapeutics, Onc.AI, Arch Oncology, Stipe, NeoTX Consulting or Advisory Role: Bristol-Myers Squibb, Merck, EMD Serono, Novartis, 7 Hills Pharma, Janssen, Reflexion Medical, Tempest Therapeutics, Alphamab Oncology, Spring Bank, Abbvie, Astellas Pharma, Bayer, Incyte, Mersana, Partner Therapeutics, Synlogic, Eisai, Werewolf, Ribon Therapeutics, Checkmate Pharmaceuticals, CStone Pharmaceuticals, Nektar, Regeneron, Rubius, Tesaro, Xilio, Xencor, Alnylam, Crown Bioscience, Flame Biosciences, Genentech, Kadmon, KSQ Therapeutics, Immunocore, Inzen, Pfizer, Silicon Therapeutics, TRex Bio, Bright Peak, Onc.AI, STipe, Codiak Biosciences, Day One Therapeutics, Endeavor, Gilead Sciences, Hotspot Therapeutics, SERVIER, STINGthera, Synthekine Research Funding (Inst.): Merck , Bristol-Myers Squibb, Incyte, Corvus Pharmaceuticals, Abbvie, Macrogenics, Xencor, Array BioPharma, Agios, Astellas Pharma , EMD Serono, Immatics, Kadmon, Moderna Therapeutics, Nektar, Spring bank, Trishula, KAHR Medical, Fstar, Genmab, Ikena Oncology, Numab, Replimmune, Rubius Therapeutics, Synlogic, Takeda, Tizona Therapeutics, Inc., BioNTech AG, Scholar Rock, Next Cure Patents, Royalties, Other Intellectual Property: Serial #15/612,657 (Cancer Immunotherapy), and Serial #PCT/US18/36052 (Microbiome Biomarkers for Anti-PD-1/PD-L1 Responsiveness: Diagnostic, Prognostic and Therapeutic Uses Thereof) Travel, Accommodations, Expenses: Bristol-Myers Squibb, Array BioPharma, EMD Serono, Janssen, Merck, Novartis, Reflexion Medical, Mersana, Pyxis, Xilio

Dr. Dionisia Quiroga discusses emerging approaches to personalizing locoregional treatment for breast cancer with Drs. Walter Paul Weber and Charlote Coles, who share insights on tailoring axillary surgery, escalating lymphatic surgery, and implementing hypofractionated radiotherapy. TRANSCRIPT Dr. Dionisia Quiroga: Hello, I'm Dr. Dionisia Quiroga, your guest host of the ASCO Daily News Podcast today. I'm a breast medical oncologist and assistant professor in the Division of Medical Oncology at the Ohio State University Comprehensive Cancer Center. On today's episode, we'll be discussing emerging approaches to personalize locoregional treatment for patients with breast cancer, including many of the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer. We're very fortunate to have joining me today for this discussion Dr. Walter Paul Weber, a professor and head at the Division of Breast Surgery at the University Hospital Basel in Switzerland, and Dr. Charlotte Coles, a professor of cancer clinical oncology and the deputy head of the Department of Oncology at the University of Cambridge in the United Kingdom. Our full disclosures are available in the transcript of this episode. Dr. Weber and Dr. Coles, it's very wonderful to have you on the podcast and thank you so much for being here. Dr. Walter Paul Weber: Thank you very much for having us. Dr. Charlotte Coles: Thank you. Dr. Dionisia Quiroga: Now, for many decades prior, axillary lymph node dissection has very much been our standard of care. But recently, axillary surgeries have been able to be gradually deescalated to spare some of our patients from relative and relevant long-term morbidity. There are still some indications in which axillary lymph node dissection still remain. And therefore, we still see breast cancer-related lymphedema, a well-known sequela of the axillary surgery to continue to be prevalent. And I think it's important also to acknowledge that today there's about an estimated 1.5 million cancer survivors who deal with breast cancer-related lymphedema. Now, Dr. Weber, at the recent ASCO Annual Meeting, you and your co-presenters discussed tailoring axillary surgery, escalating lymphatic surgery and implementing evidence-based hypofractionated radiotherapy to really personalize locoregional treatment for people who've been diagnosed with breast cancer. And in addition to that, you and Dr. Coles have also published this work in the 2024 ASCO Educational Book. Can you tell us about some of the recent advances in axillary surgery and what are really the current indications for axillary dissection? Dr. Walter Paul Weber: Yes, I'm happy to do so. So as you've said, we've known for a while that we can omit axillary dissection in patients with clinically known negative breast cancer and negative sentinel nodes. We've known for about 10-15 years that we can omit axillary dissection in patients with one or two positive sentinel nodes in many patients. But what we've learned recently is that we can omit axillary dissection also in patients with one or two positive sentinel nodes who have larger primary tumors who undergo mastectomy or who have extranodal extension. This is a landmark trial that was published just a few months ago, the SENOMAC trial that established this. The remaining indications for axillary dissection are situations where you expect a heavy tumor load in the axilla. For example, when you have more than two positive sentinel nodes or you have a patient with clinically node-positive breast cancer who undergoes upfront surgery and has palpable disease or significant disease on imaging. Patients with locally advanced breast cancer, who are considered by some to be not eligible for nodal downstaging, such as patients with CN2, CN3 disease or CT4 breast cancer. And then the big group of patients who have residual disease after neoadjuvant chemotherapy in the nodes, standard of care is still axillary dissection. But we now have some real-world evidence that it's safe for selected patients with low volume nodal disease left in the nodes, mostly isolated tumor cells, to not undergo axillary dissection. So these are the remaining indications today. Dr. Dionisia Quiroga: Can you speak to situations where maybe even sentinel lymph node biopsies might be omitted? I know you spoke a little bit about the use of imaging in your work. Dr. Walter Paul Weber: Yes, this is correct. So, we started about maybe 7 or 8 years ago to omit sentinel lymph node biopsy in older patients above 70 years of age who have luminal disease, according to recommendations from the Choosing Wisely initiative. And now indeed there are several ongoing randomized trials that investigate if axillary imaging can replace surgical staging of the axilla. And the first of these trials was published recently, the SOUND trial with almost 1,500 patients, who underwent breast conserving surgery and had small tumors and all had a negative ultrasound of the axilla. And then they were randomized into a sentinel lymph node biopsy versus no axillary surgery. And that trial showed non-inferiority of the omission of sentinel lymph node biopsy in these patients. Now, it's a bit early to roll out the Choosing Wisely recommendation to all patients who have a negative ultrasound. The SOUND trial showed that about 14% had a false-negative ultrasound. So, in the control arm, they actually did have a positive sentinel node. And in patients where that one missed sentinel node makes a big difference in terms of systemic therapy, most experts would still recommend sentinel biopsy, and these are patients mainly with HER2-positive or triple-negative breast cancer or premenopausal patients or those who have G3 biology. Dr. Dionisia Quiroga: I think you bring up a very important point. Coming from the side of a breast medical oncologist, we're also very interested to see what these studies show because many of our practices are based on what we find out from our lymph node biopsies. So, I think a lot of interesting prospective studies to look at in the future. Dr. Walter Paul Weber: Absolutely. Dr. Dionisia Quiroga: One other topic we wanted to discuss was local regional management of stage four disease and particularly oligometastatic disease. And this is not a new topic of interest. We've been speaking about this for a long time in breast cancer management, but can you address some of the axillary management strategies that you currently use for stage 4 disease? Dr. Walter Paul Weber: Yes, it depends on your intention. If your intention is to cure the patient, then you would apply all the locoregional standards that apply in the curative setting, which means lymph node biopsy with or without axillary dissection. Now in a palliative situation, it's individualized. Very often you don't touch the axilla and sometimes you open it and just remove palpable disease, trying to minimize morbidity. The question of which intent you should follow is controversial; three out of the four randomized trials did not show a benefit for locoregional surgery in patients with de novo stage 4 disease. However, experts seem to disagree. The last St. Gallen consensus recommendation was in favor of the curative intent in such a patient with oligometastatic disease; 85% favored the curative intent. So there's a bit of discrepancy there, but everybody would agree, and this is what has been done in all of these trials, that if you try to cure the patient, then you should apply the curative standards of sentinel and axillary dissection that you use also in early-stage breast cancer. Dr. Dionisia Quiroga: Thank you. Now, moving on from surgical axillary management and more into lymphedema prevention and treatment. Can you speak to some of the promising advances that have happened in this field? Dr. Walter Paul Weber: Yes, so the best way to prevent lymphedema still is not to perform axillary dissection, which is the number 1 risk factor, which is all the axillary surgery de-escalation research that we've just discussed is all about. Prevention of lymphedema is one major aim of this. Now, once you indicate axillary dissection and you expect the patient to be at high risk – for example, if there are other risk factors such as obesity or neoadjuvant chemotherapy or extended regional nodal radiotherapy, then indeed there are emerging techniques that really seem to work. There is some evidence supporting it, which is categorizable as immediate lymphatic repair basically or bypass. And that is usually in a patient who undergoes axillary dissection, and also undergoes axillary reverse mapping. That allows the identification of the lymph nodes that are probably most relevant to the drainage of the lymphatic fluid from the arm. And then you can try to spare these. But if you decide, and this is effective, there is a consistent body of evidence, not phase 3 trials, but pretty consistent evidence that axillary reverse mapping works just by sparing the identified nodes. But if you decide that you have to remove these nodes as part of the radical concept of axillary dissection, then immediate lymphatic repair is also increasingly being done and is also supported by consistent evidence, even some single center randomized trials, low volume, but all consistently showing quite a striking benefit of this immediate lymphatic repair technique. There are different ways you can do it. You can either use it the microscope, and it's being done by the plastic surgeons, but it's also a simplified technique described that can be used by specialized general and breast surgeons. Both techniques seem to really work based on what we know from the studies, but also based on our common sense. Dr. Dionisia Quiroga: You talked about the procedures that can be offered to patients at time of breast surgery. And unfortunately, many of our patients maybe did not have the availability of those techniques when they undergo their initial breast cancer treatment. Once lymphedema is developed in a limb following breast cancer diagnosis, can you speak to other interventions that can be done to potentially help mitigate lymphedema? Dr. Walter Paul Weber: Right, so for patients who no longer benefit from or wish to further undergo conservative treatment of lymphedema, there are emerging procedures that are now out of my personal comfort zone because they're being performed by plastic surgeons; they use the microscope. There are two groups, the lymphovenous anastomosis and then the real vascular lymph node transfer as a free flap. And both of these procedures (there are no randomized trials yet published), but some really good ones are on the way and currently recruiting based on the evidence we have, which is over 20 observational studies all consistently again showing a benefit in terms of what you can measure in terms of centimeters or with a bioimpedance spectroscopy, or also when you ask the patients, you see quite some dramatic improvements by both of these techniques. And it's increasingly being done. Personally, I strongly believe that it works based on everything we know and understand from lymphedema development, but also prevention and treatment. So I am quite sure that in 5-10 years, we will see much more surgical treatment of patients with lymphedema by highly specialized plastic surgeons. Dr. Dionisia Quiroga: That's my hope as well. Now, another important component of local regional treatment we know is of course radiotherapy. And there have been many incredible advances in breast radiotherapy over the past decades, which has really improved cancer control and decreased side effects in our patients. Dr. Coles, you've led practice changing radiotherapy trials in the past and your research has really influenced international hypofractionation policy. Can you expand upon the emergence of hypofractionated radiation for breast cancer and the effects that it can have on our patient care? Dr. Charlotte Coles: Yes, so thank you very much, Dr. Quiroga. So I think the first thing to say is that radiotherapy hypofractionation isn't a new concept. And in fact, the breast radiotherapy hypofractionation trial started around three decades ago. And the rationale for this was the hypothesis that breast cancer is as sensitive to fraction, which is the treatments that we give, we split it into fractions, is sensitive as late responding tissue. So what does this mean? It means that the small traditional 2 Gy fraction spare tumor and normal tissues equally, so there's no advantage. So therefore, fewer fractions with a larger dose per fraction are worth testing. The problem is there's a concern that hypofractionation might increase the risk of side effects, and that includes the really important one we've been talking about, lymphedema. But we can reduce this risk by reducing the total radiotherapy dose over the whole course. But the question was by how much. So that's why randomized trials were needed. And there's been really high-quality trials with robust radiotherapy quality assurance, and they've been designed in partnership with patients. So just a very quick run through: A landmark trial was the UK START B trial. And this was a pragmatic design that compared 50 Gy in 25 fractions, which was commonly used in the south of the country with 40 Gy in 15 fractions, which was used at that time in the north [of the UK]. And this recruitment was around in the late 1990s and early 2000s. What we knew was that the three-week regimen was actually radiobiologically lower dose. And therefore the results that we got, it wasn't surprising that the 40 Gy was actually gentler on the normal tissue. So that's an advantage for patients. But what was surprising was it wasn't gentler on the tumor and non-inferiority was proven. So this suggests that overall treatment time is important for local control. So this fits with hypofractionation. Way back in 2009, 40 Gy in 15 fractions to both the breast and regional nodes became standard of care in the UK. But five-week nodal and actually breast as well remained standard of care in many countries for many years after that, a little bit to do with the fact that there were few patients treated in the START trial in terms of treating the node. So more recently we've had more randomized trials, particularly for nodal radiotherapy. And this includes the recently reported Danish SKAGEN 1 trial and also the French HypoG-01 trial, which was actually presented at ESMO in Barcelona a couple of weeks ago. So we've now got data for over 5,800 participants in really high-quality randomized trials testing three weeks and five weeks of nodal radiotherapy. And there's no statistically significant difference in late normal tissues for any of these, including lymphedema. So certainly, in my opinion and reflecting in many of the European guidelines, five-week radiotherapy is no longer indicated and three-week nodal radiotherapy is the international standard of care. So, in conclusion, the question is can we hypofractionate even further? So the UK FAST-Forward trial tested three weeks with two different dose levels of one week for the whole breast. Primary endpoint was ipsilateral breast tumor response. More than 4,000 patients participated and this was reported in 2020 with a median follow -up of six years and this was very timely because this is a time of COVID and the results showed non-inferiority for local control with similar late normal tissue side effects and we've also had other results from the UK IMPORT HIGH trial which shows that we can safely deliver a small, highly targeted team of boost simultaneously with the whole breast in all in three weeks. Finally, these two landmark trials have come together for the design of the UK FAST-Forward Boost Study led by my colleague Dr. Anna Kirby. And this is going to test three-week simultaneous integrated boost with two levels of one-week simultaneous integrated boost. And it's also going to test the safety of 5 fraction nodal radiotherapy, including the internal mammary node. Primary endpoint is ipsilateral breast tumor response, multiple normal tissue endpoints, including patient-reported outcomes of course, and the target recall is large with 4,800 participants. So, in summary, I would say that hypofractionation is efficacious, has similarly reduced toxicity. Importantly, it reduces patient burden and that's incredibly important because it means that people can get back on with their life quicker. It reduces health system costs, and also increases equity of access. So we really do need to continue to recruit and design high quality trials in this area. Dr. Dionisia Quiroga: Thank you, Dr. Coles. I think you highlight that there really aren't any downsides to looking into hypofractionated radiotherapy at this point. So excited to see what those future trials yield. And I want to thank you so much, Dr. Weber and Dr. Coles for sharing your valuable insights with us today on the ASCO Daily News Podcast. Dr. Walter Paul Weber: Thank you very much. Dr. Charlotte Coles: Thank you. Dr. Dionisia Quiroga: And thank you to our listeners for joining us today. Our listeners will find a link to our guests' article from the ASCO Educational Book in the transcript of this episode, as well as a link to their presentation from the most recent ASCO Annual Meeting. 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 podcast. 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. Dionisia Quiroga @quirogad Dr. Walter Paul Weber Dr. Charlotte Coles Follow ASCO on social media:     @ASCO on Twitter    ASCO on Facebook    ASCO on LinkedIn    Disclosures: Dr. Dionisia Quiroga: No relationships to disclose Dr. Walter Weber: Honoraria: MSD Dr. Charlotte Coles: No relationships to disclose

JCO PO author Dr. Amar U. Kishan, Professor, Executive Vice Chair, and Chief of Genitourinary Oncology Service in the Department of Radiation Oncology at the University of California, Los Angeles, shares insights into his JCO PO article, “Transcriptomic Profiling of Primary Prostate Cancers and Nonlocalized Disease on Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography: A Multicenter Retrospective Study.”  Host Dr. Rafeh Naqash and Dr. Kishan discuss the relationship between Decipher genomic classifier scores and prostate-specific membrane antigen (PSMA) PET/CT-based metastatic spread. 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 articles. I'm your host, Dr. Rafeh Naqash, Assistant Professor at the OU Health Stephenson Cancer Center at the University of Oklahoma. Today we are joined by Dr. Amar Kishan, Executive Vice Chair of the Department of Radiation Oncology at the David Geffen School of Medicine at UCLA and UCLA Jonsson Comprehensive Cancer Center, and also the corresponding and senior author of the JCO Precision Oncology article entitled, “Transcriptomic Profiling of Primary Prostate Cancers and Non Localized Disease on Prostate-Specific Membrane Antigen (PSMA) Positron Emission Tomography/Computed Tomography: A Multicenter Retrospective Study.” Dr. Kishan, welcome to our podcast and thank you for joining us today. Dr. Amar Kishan: Thank you so much for that kind introduction and the invitation to be here today. Dr. Rafeh Naqash: Well, it seems to me that there's a theme that people in the GU space, investigators in the GU space, are very interested in trying to understand risk predictors for prostate cancer. We had somebody, I believe from Huntsman Cancer Center a few months back on a previous podcast, where they were trying to do risk prediction modeling as well. Could you tell us why that's something that the GU community is very interested in? What's the background? Is it because there's no risk prediction approaches currently? And would this somehow influence management in the near future? Dr. Amar Kishan: Yeah, that's a great question. So, I think this goes back to the point that we're in the era of precision medicine now, and many cancers have these molecular stratification scores and all that. Prostate cancer has lagged a little bit behind in that regard, despite the fact that it's such a common cancer that affects so many people across the country and across the world. So, we do have risk stratification schemes for prostate cancer. These are based off clinical and pathologic variables, like the level of PSA, the size of the tumor on digital rectal examination, now, we're incorporating MRI imaging as well, and then what the cancer looks like under the microscope, the Gleason score. And now there have been revisions to the Gleason score, but it's really kind of the architecture, what the biopsy looks like. And this was kind of developed many, many years ago by Donald Gleason, a pathologist at the VA. What we're not necessarily taking into account routinely is kind of the biology of the cancer per se. You know, what are the molecular drivers? How could that influence ultimate outcome? And that's very important because we have these risk groups, low risk, very low risk, favorable intermediate risk, unfavorable intermediate risk, high risk, very high risk. But within each of those groups, based on the clinical kind of pathological characteristics, there's a huge heterogeneity in outpatients too, and our treatments are effective, but they can be morbid. Putting someone on hormone therapy for an extended period of time has a lot of side effects. Dose escalating radiotherapy or doing surgery and then radiation afterwards, these are big things that have a big impact on the patient, and I think we really need better risk stratification tools to understand who needs intensification and who we can de-escalate treatment for. Dr. Rafeh Naqash: I think those are absolutely valid points, perhaps not just for prostate cancer, more so for all cancers that we currently treat, especially in the current day and age, where we have a tendency to add more and more therapies, combination therapies for patients, and as you mentioned, risk stratification to help identify high risk versus low risk, where you can de intensify treatment, is of high value from a patient standpoint as well as from a financial toxicity standpoint. So then, going to this next part of the approach that you used, and from what I understand in this paper, you had the radiological aspect, which is the PSMA PET, which we'll talk about. Then you had the genomic aspect, where you did some genomic risk-based stratification. Then you had the transcriptomic score based on the Decipher score. So, could you go into some of the details, first, for the PSMA PET, when is it used? What is the utilization? What is it based on, the science behind the PSMA PET? And then we can talk about some of the other genomic transcriptomic predictors that you use in this study. Dr. Amar Kishan: Sure. Absolutely. So, a PSMA PET is an advanced molecular imaging tool. PSMA stands for prostate specific membrane antigen. It's a membrane protein that is expressed on the surface of prostate cancer cells. It is expressed elsewhere in the body as well. The utilization of this for imaging has been a revolution in the staging of prostate cancer, both upfront and in the recurrent setting. We basically had fairly recent approval for PSMA PET being used more routinely in upfront staging and recurrent staging in 2022. Essentially, what this is it gives us an ability to detect whether prostate cancer has spread at a time of diagnosis or try to localize the recurrence. Now, no imaging test is perfect, of course, and a PET has a resolution of about 3 mm. There are questions about the sensitivity of the PET. You get it on a patient with high-risk disease, the PET is negative; you do surgery, there are positive lymph nodes. That can happen, but it's far superior to the tools that we have had before. For instance, beforehand, all we would have is a contrast enhanced CT, bone scan, and MRI. And the sensitivity of those is far below that of a PSMA PET. And that has actually been shown in a randomized trial called the ProPSMA trial out of Australia, where they compared conventional upfront imaging versus PSMA upfront imaging with a crossover design, and there was better detection of disease with the PSMA PET. So that's been a revolution in how we stage prostate cancer. But I'm sure many of your listeners and others are aware of the concerns. When you get a new test and you're detecting disease that's extra prostatic, for instance, are you seeing truly significant new disease that we do need to change our management for, or are we just seeing stuff that wasn't there before that actually wouldn't impact anything? And what I mean by that is, let's say you're seeing things that would never have made a difference to the patient, but now you're saying they have metastatic disease. You're changing their entire treatment paradigm, all kinds of things like that. There's implications to this that hasn't been fully fleshed out. But very recently, like we're talking in July of 2024, essentially, there was a Lancet Oncology paper that looked at the long-term prognosis of patients who had extra prostatic disease on PSMA PET, judged by something called a PROMISE score, kind of gives a quantification on the volume of disease, the brightness of disease, and they correlated that with long term outcomes. And that was really the first time that we have long term follow up data that this extra prostatic disease on PSMA PET actually is prognostically important. So, we're getting there. I mean, now that it's approved and, in some sense, the cat is out of the bag, patients are coming in asking for a PSMA PET, etc. I'm sure everyone has experienced that, but I think we now do have good evidence that it actually is prognostically important as well. Dr. Rafeh Naqash: Thank you for that explanation. And again, to put this into context for things that I've seen and that might also help the listeners in other tumors, so, for example, melanoma surveillance tends to be or while on treatment, patients tend to have more PET scans than what you see, maybe in individuals with lung cancer, where you get a baseline PET and then you have follow up CT scan based imaging is that something that you guys have shifted from in the prostate cancer space with the approval for PSMA PET, where follow up imaging, whether patient is on treatment or surveillance imaging, is PSMA PET based? Dr. Amar Kishan: Yeah, that's a good question. I think there's actually less robust data to support it as a means of treatment response. But in terms of evaluating a recurrence, then, yes, that has become kind of a standard tool. It's very complicated because all of the metrics that we have for, say, a treatment failing are based on conventionally detected metastases or something that shows up on a CT or bone scan. So, again, that question arises if someone is on systemic therapy and then you see something on a PSMA PET, are you going to abandon the therapy that you're on? It technically would be earlier than you would otherwise have done that, or what are you going to do? So, that hasn't been fully fleshed out, but it is used in that circumstance. So, I'd say less for treatment monitoring and more for evaluation of suspected recurrence. Dr. Rafeh Naqash: Understood. And I'm guessing, as a futuristic approach, somebody out there may perhaps do a trial using PSMA PET based imaging to decide whether treatment change needs to be made or does not need to be made. Dr. Amar Kishan: Yeah. It is being incorporated into trials as we speak, I think. Dr. Rafeh Naqash: Now, going to the second part of this paper is the Decipher score. Could you explain what the score is, what its components are, how it's calculated? Is it DNA, is it RNA, is it both combined? Is it tissue based; is it blood based? Dr. Amar Kishan: Yeah. So, the Decipher is also an approved test now, was approved in 2018. What it is, essentially, and how it's derived is based on the idea originally that patients might have a recurrence after surgery for prostate cancer. And it's just a PSA recurrence. It's this way. It's literally what we call a biochemical recurrence. That patient might not have any problems, whereas other patients with a recurrence might go on to develop metastatic disease. And we didn't have a good way of determining which patient is which. Get back to that prognostic problem that we have. So, some investigators, they looked at men that had radical prostatectomy from 1987 to 2001 at the Mayo Clinic that had archived tissue. They looked at FFPE, or basically paraffin embedded tissue. They extracted the RNA and then did a microarray analysis and looked at transcriptomic signatures and wanted to see, could this discern the patients who had mets, who had clinically significant recurrences from those that didn't? And out of that exercise came the Decipher Genomic Classifier, which basically is based on 22 genes. These are involved with cell proliferation, etc., but it's an RNA-based, tissue-based assay. So, if you wanted to order a Decipher on somebody, you would need to use a biopsy or prostatectomy specimen to do so. Essentially, that the samples, they would take the highest grade, highest Gleason grade specimen, send it to their lab. Their main lab is in California. The company is called Veracyte. And then they will do this RNA express analysis with a microarray and then return a score. The score is 0 to 1. Basically, 0 is the lowest, one is the highest, and it is a way of prognosticating the risk of metastasis. Originally, when you get a Decipher report, it actually will tell you the 5 and 10-year risks of distant metastasis, and we'll quantify that. Dr. Rafeh Naqash: And you said this is approved or has been approved in 2018. So, is this insurance reimbursable at this point? Dr. Amar Kishan: Most insurances do, not all, and the criteria for getting it can vary, so we can talk about it, but it was initially developed in this post-op setting. On the basis of a significant amount of validation studies, it has been moved to being used in the upfront setting as well. So, if you look at some of the ongoing NRG trials, for instance, they are stratifying patients based off the upfront Decipher score. And this is based off of validation studies that have been conducted looking at past RTOG trials and other trials. That said, sometimes it is not approved by commercial insurances in the upfront setting, because that wasn't where it was initially validated and derived. But honestly, here in 2024, that's very uncommon. It's much more common that it's approved. Dr. Rafeh Naqash: Understood. And in your practice, or the medical oncologist practice at your institution or other institutions, is this something that is commonly used for some sort of treatment decision making that you've seen? Dr. Amar Kishan: Yeah. So, as a radiation oncologist, I do think it's a useful test, because my approach is, if we're talking about adding hormone therapy, for instance, which is oftentimes dominating the conversation, we know that it offers a relative benefit to a lot of patients. We've published on this; others have published on it. Let's say it reduces the chance of metastasis by about 40%. 10-year risk of metastasis has a ratio of 0.6. So, 40% reduction. But if your risk of metastasis is 2%, that benefit is not that much in absolute terms. And we don't historically have a great way of saying, what is your absolute risk of metastasis? And I think Decipher is one tool that does tell us that - it literally gives it on the report. Now, is that a holy grail? Is it 100% accurate? Nothing is 100% accurate. But it does give us some quantification. Then I can go back to the patient and say, yes, you will get a benefit from adding hormone therapy, but you're talking about going from 2% to 1%, and so they can decide if that's worth it to them. Conversely, it could be a situation where they really don't want hormone therapy, but it comes back that their risk of metastasis is 20%, and then there's actually a big absolute benefit. So that's how I use it as a radiation oncologist, and we would use it upfront. Now surgeons, and if I was consulting on a post operative patient, maybe it plays more of a role. And do we need to do post operative radiotherapy on this patient, or do we need to add hormone therapy in the postoperative situation? From the medical oncology perspective, there are emerging data that may be useful in the choice of systemic therapy for metastatic disease, but that is a little bit earlier in the investigational stage, I would say. So, when I'm working with medical oncologists, it's often still in this localized setting, and typically, do we add hormone therapy or not, and that type of thing. Dr. Rafeh Naqash: Understood. And from a reporting standpoint, so the Decipher score, I'm guessing it's some sort of a report that comes back to the ordering physician and you basically see the score, it gives you a potential recurrence free survival percentage or a metastasis percentage of what is your risk for having metastasis in the next five years - is that how they generally do it? Because I've personally never seen one, so I'm just curious. Dr. Amar Kishan: Yeah, essentially, it comes back with a score, a numerical score, again, from 0 to 1, and it will basically give you the five-year risk of distant metastasis. The ten-year risk of distant metastasis. You can request an extended report that provides additional, not as well supported signatures that are out there, like ADT response signature, etc. But those maybe may have been published, but are not clinically validated as much, but the actual Decipher report, which goes to patients too, just has this kind of 5,10-year risk of distant metastasis. They have some estimations on prostate cancer specific mortality as well. Dr. Rafeh Naqash: Sure. Now, the third part of this project, and correct me if I'm wrong, the grid database of the 265 genomic signature score. From what I understood, this is a different component than the Decipher score. Is that a fair statement? Dr. Amar Kishan: Yeah. No, that's exactly correct. And that was an exploratory part of this analysis, to be honest. Basically, I think our main focus in the paper was those advances that we've talked about PSMA and Decipher, those happened concurrently. People started developing PSMA PET, people started developing Decipher. And so, what we wanted to understand was, if you have a patient that has extra prosthetic disease on PSMA PET, are those biologically more aggressive cancers, is their Decipher score going to be higher? What can we learn about the biology of this? And we were the first, to my knowledge, where we actually had a large data set of patients that actually received PSMA PETs and Decipher. And that's kind of the gist of the paper. We have patients in the upfront setting, patients in the post radical prostatectomy setting, and we're essentially showing that there is this correlation. In the upfront setting, the odds of extra prosthetic disease are higher for higher Decipher scores, which is kind of maybe validating that this biology is capturing something that's akin to this ability to spread. And in the post-op setting, because we have time to failure, technically, we can calculate a hazard ratio rather than odds ratio. So, we have a hazard ratio that's significantly associated with an increased risk of spread for patients with higher Decipher. The grid portion, which is the genomic resource information database, was more of an exploratory part where I mentioned the Decipher score is based off this microarray, they're looking at 1.4 million transcripts. Only 22 are part of the Decipher, but you can request the rest of the signature data as well. And so, we wanted to look at other pathways, other signatures that have been published, like looking at DNA repair, neuroendocrine pathway, just to see if we could see any correlations there that's not necessarily as clinically actionable. These are more exploratory. But again, we were trying to just look at whether patients who had non localized disease on their PSMA PET, whether their primary had more aggressive biology. We did see that. So that's kind of loosely speaking things like PTEN loss, androgen receptor, DNA repair, metabolism, neuroendocrine signaling, which are thought to be portenders of aggressive disease. Those pathways were upregulated at the RNA level in patients who had non-localized disease. And that's kind of the take home from that. But I wouldn't say any of that is clinically actionable at this point. It's more kind of defining biology. Dr. Rafeh Naqash: Some of the interesting correlations that you make here, at least in the figures that we see, you're looking at different local occurrences, nodal metastases, M1A and M1B disease. And one thing that I'm a little curious about is the Decipher score seems to be lower in pelvic nodal metastasis, that is, PSMA PET positive versus local recurrence, which has a slightly higher Decipher score. Is that just because of a sample size difference, or is there a biologically different explanation for that? Dr. Amar Kishan: Yeah, that's a good point. I would assume that's probably because of a sample size in this case, and it's a little bit complicated. It wasn't statistically different. And it was 0.76 on average for patients with local recurrence and 0.7 for patients with a pelvic nodal metastasis. Well, what I think is interesting is we can maybe think that in this post-op setting the time to failure could have been long in some of these cases. So, it is conceivable that an isolated nodal recurrence 10 years after the surgery, for instance, is not as aggressive a cancer as a local recurrence in a short time after the surgery. And that's not taken into account when you're just looking at median scores like we are in this fox and whiskers plot. But overall, I think what it's suggesting is that there are patients who have more indolent disease. That's actually pretty widespread there. There are pretty indolent cases that have these nodal metastases. So just because you have a nodal metastasis doesn't mean it's an incredibly aggressive cancer, biologically. Dr. Rafeh Naqash: Now, the exploratory component, as you mentioned, is the grid part where you do look at TP53, which is a cell cycle gene, and higher TP53 associated with worse recurrences, from what I understand. Do you see that just from a cell cycle standpoint? Because from what I, again, see in the paper, there's a couple of other cell cycle related signatures that you're using. Is that just a surrogate for potential Gleason score? Have you guys done any correlations where higher Gleason score is associated with maybe higher cell cycle checkpoint, pathway related alterations and replication stress and DNA damage and perhaps more aggressive cancers? Dr. Amar Kishan: Yeah, that's a great question. We haven't done that in this paper, but it has been published before that there is this correlation loosely between grade and some of these parameters - so repair, metabolism, androgen receptor signaling. However, it's a very great point that you bring up, which is that it's pretty heterogeneous and that's why we need something like this as opposed to Gleason score. So, you can have Gleason 10 cancer. I mean, that would be pretty uncommon. But within the Gleason 9, at least, which we have published on and looked at, there's a heterogeneity. There are some that are biologically not that aggressive. And the converse Gleason 7, you can have some that are actually biologically aggressive. That's why it may be useful to move away from just the pathological architecture and get a little bit more into some of these pathways. Dr. Rafeh Naqash: What's the next step here? I know this perhaps isn't ready for primetime. How would you try to emphasize the message in a way that makes it interesting and clinically applicable for your colleagues in the GU community? Dr. Amar Kishan: Yeah. I think for me, what I would try to emphasize here and what I think is the main takeaway is this is kind of a validation that having extra prostatic disease on PSMA PET is likely suggestive of a more aggressive disease biology. And I think what this stresses to me is the importance of getting a PSMA PET, particularly in patients with high-risk prostate cancer. This isn't always happening. And I think if we see things on a PSMA PET, we really need to consider systemic therapy intensification. And what do I mean by that as a practical point? You have a high-risk prostate cancer patient. You get a PSMA PET, you see an isolated pelvic lymph node. If we believe the results of the study, that's a more aggressive biology likely. Whether we have the Decipher or whether we have genomic signatures, which we may or may not have, maybe that patient should get treated with something like an androgen receptor signaling inhibitor in addition to ADT, more akin to a clinically node positive case. So, intensify the systemic therapy, more aggressive disease. That's how I would incorporate it practically into my practice, that really what we're seeing on the PSMA PET is real. It's a reflection of biology that's aggressive. It's not just some Will Rogers effect where you're upstaging stuff needlessly. I think this is telling us some true biology. So that's kind of what my takeaway would be. I think future areas of investigation would be, honestly, to try to have a better idea of what's going on in these metastases. So, if you could design a study potentially, where your biopsy some of these and actually do sequencing and understand a little bit more of that. And so, we're looking into stuff like that. But my takeaway for like the everyday clinician would be to try to get a PSMA PET, if you can, and to intensify therapy on the basis of that, or at least consider it, discuss it in a multidisciplinary setting. Dr. Rafeh Naqash: And I'm guessing somebody out there, perhaps even you, are thinking or planning on doing a ctDNA MRD based correlation here, since that's up and coming in this space. Dr. Amar Kishan: That is up and coming, I think one of the challenges in prostate cancer is the amount of ctDNA can be low. But yes, you're right, that's certainly things that a lot of us are looking at, too. Dr. Rafeh Naqash: Excellent. Well, thank you for the science discussion, Dr. Kishan, could you tell us a little bit about yourself, your career trajectory, where you started, what you're doing, and perhaps some advice for early career junior investigators, trainees, things that might have worked for you, that could also work for them as they are progressing in their careers. Dr. Amar Kishan: Sure. So, yeah, I'm a radiation oncologist at UCLA. I run the prostate cancer radiation program. Clinically. I'm also heavily involved in our research enterprise, so I kind of oversee the clinical and translational research aspect. That's what I do currently. So, I did my residency in radiation oncology at UCLA. Just on a personal note, my wife is from LA, her parents live in LA. We really wanted to stay in LA, so I was fortunate to be able to join the faculty here. I always liked GU oncology, so that was kind of a natural thing for me to kind of go into this position here and try to build the GU program. I've been very fortunate to have great collaborators. My message to students and trainees is to try to reach outside your department for mentorship as well. It's important to have people inside your department who can mentor you. But as a radiation oncologist, I work so closely with urology, so closely with medical oncology that I'm very fortunate to have individuals in those departments who have a vested interest in me and my success as well. I like working with them. It's important to be a team player. If they need help, you help them. If you need help, you ask for help from them. So, I think that's the single biggest thing that I would say to any trainee is don't be intimidated. Please reach outside of your department. Lots of people are willing to help and provide mentorship, and it's helpful to have that perspective. We are in a very multidisciplinary environment and era of practicing medicine. Dr. Rafeh Naqash: Well, thank you again for those personal insights and especially for submitting your work to JCO PO. And we hope to see more of this work perhaps in the subsequent sessions for JCO PO, and maybe we'll bring you back again. And at that point, the Decipher and the PSMA PET scan will have more data, more implementation in the clinically relevant real-world setting. Dr. Amar Kishan: Thank you very much. And if I could just give one quick shout out. The first author of this work, which I presented, was Dr. John Nikitas, who is a trainee that works with me here at UCLA a PGY5 resident. So, I do want to give credit to him as well. Dr. Rafeh Naqash: And John, if you're listening to this hopefully, it's always great to get a shout out from your mentor. Thank you both again for putting in the work and effort to submit this manuscript. 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 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.    Disclosures  Dr. Kishan Honoraria Company: Varian Medical Systems, Boston Scientific,  Janssen Oncology  Consulting or Advisory Role Company: Janssen, Boston Scientific, Lantheus  Research Funding Company: Janssen , Point Biopharma

Dr. Merry Jennifer Markham and ASCO CMO Dr. Julie Gralow discuss the shortage of IV fluids and other challenges that have emerged from Hurricane Helene as high-risk areas brace for impact from another storm, Hurricane Milton. In a conversation with Dr. John Sweetenham, they highlight resources for oncologists and patients and stress the importance of crisis preparedness at cancer centers. TRANSCRIPT Dr. John Sweetenham: Hello, I'm Dr. John Sweetenham, the host of the ASCO Daily News Podcast. Hurricane Helene made landfall on September 26th in Florida and raged over parts of Georgia, North Carolina, Tennessee, and Virginia. The disaster has claimed over 230 lives. Many people are still missing, and many thousands are homeless. The hurricane has exacerbated the nation's IV fluid shortage, and some health care facilities have begun implementing conservation strategies. Meanwhile, Hurricane Milton, another powerful hurricane, is expected to wreak havoc as Florida braces for back-to-back hurricanes in parts of the state. On today's episode, we'll be discussing the impact of these events on cancer care, including the shortage of IV fluids. Joining me for this discussion is Dr. Merry Jennifer Markham, a professor and research lead for the University of Florida Health Cancer Center's Gynecologic Cancer Disease Site Group. I'm also delighted to welcome Dr. Julie Gralow, the chief medical officer at ASCO. Our full disclosures are available in the transcript of this episode. Merry Jennifer and Julie, many thanks for joining us for the podcast today. Dr. Julie Gralow: Thanks for having us, John. Dr. Merry Jennifer Markham: Yes, thank you. Dr. John Sweetenham: Merry Jennifer, can you tell us your exact location today and how your patients and institution have been impacted by Hurricane Helene so far? Dr. Merry Jennifer Markham: I am in the north-central part of Florida. I'm in Gainesville, Florida, which is the home of the University of Florida, where I practice medicine. And we are physically about two hours north of Tampa, two hours north of Orlando, and about an hour and a half southwest of Jacksonville. So right in the middle. And we are currently in the track for the next storm. Helene was a really a devastating storm and what our area felt was primarily what we tend to get in most storms here in the center part of the state, which is a lot of rain, a high risk for tornadoes and a lot of power outages. And one of the challenges that my center in particular faces, and some of the local cancer centers and cancer care providers around in our region, is our patients live in a very rural population. So for those patients who are not in downtown Tampa, downtown Orlando, for example, the rest of the state, especially in the northern part, tends to be quite rural. And so many of our patients had loss of power and a lot also in those regions are on well water. And so when the power goes out, it's not just a matter of losing air conditioning and losing access to Wi-Fi, but it's also losing access to fresh, clean water. Dr. John Sweetenham: Wow, it sounds very challenging. And of course, there are growing concerns at the moment about the IV fluid shortage that's being caused by Hurricane Helene and some hospitals have already begun conserving IV fluid supplies. Can you tell us a little bit about your experience with IV fluid shortages so far and whether you are anticipating other medical supplies to be affected by these shortages in the days or weeks ahead? Dr. Merry Jennifer Markham: Well, the IV fluid shortage has definitely impacted us. I happened to be on service last week and this week, and, working in the inpatient setting right now on our oncology inpatient service, we are having to conserve all IV fluid, and the entire hospital has been directed to find workarounds. And it's not always easy to find workarounds. It has definitely impacted our ability to safely discharge patients and to sometimes adequately give people the hydration, for example, that they need. A lot of the cancer therapies, we also use intravenous fluids to pre-hydrate or post-hydrate, and it's a challenge when we also need to conserve those IV fluids for other critical needs in the hospital setting. And for me, the shortage is really being felt in that inpatient setting right now. I think that other centers are still going through. And what we learned from the pandemic is that when there is a shortage, and it's not just actually the pandemic that we learned this from, but from any of the supply chain issues that we've had is then centers start buying it up, right? And so there's a bit of a panic in the healthcare field where if we're short on IV fluids, then well, now everybody is buying up the remaining IV fluids. And I think that does impact, unfortunately, everyone in a negative way. Dr. John Sweetenham: Yeah, I was reading some news reports earlier today actually about stockpiling and the efforts that some of the companies are going to control their outward going supplies to hopefully prevent some of that stockpiling. As if life for you and your patients wasn't difficult enough, you now have the prospect of another major storm, Hurricane Milton, which is headed your way and predicted to be among the most destructive hurricanes ever on record in central Florida. What are your major concerns in the days ahead and for what this might mean for the longer-term impact on cancer care? Dr. Merry Jennifer Markham: It's concerning. We are definitely in the path and the hospital is currently in sort of crisis preparedness mode. My concerns are always for the patients and for the teams caring for them, especially in my current work in the inpatient setting, these last two weeks. Our patients, because they come from such rural areas, are going to lose power. We will probably lose power, but we have generators at the hospital system, so we're a bit protected. But in many of these areas around us, there will be high winds, there will be flooding for those along the coast, and just the access to a clean, safe living environment is going be in jeopardy during and after the storm. What concerns me about our patients in particular with cancer are the ones who are undergoing treatments and who may have complications and may not be able to reach the help that they need during the storm or in the days following. I have patients that I have been caring for in the last week who still haven't recuperated, still haven't recovered their power from Helene. And so this is just adding insult to injury. I think that the impact on medical supplies is still to be seen. The challenge is always when a storm wipes out the major manufacturer of a particular product, I think we'll probably continue to have the IV fluid shortages. And I think it's just going to be a matter of preparing for a worst-case scenario but being prepared. Dr. John Sweetenham: Absolutely, yes. I think you've already alluded to the fact that as each of these successive disasters affect the country, we sort of learn a little bit more each time. And ASCO has provided resources on its website for disaster assistance. We'll share a link in the transcript of this episode to connect providers and patients to the Hurricane Helene-specific resources, government agencies, and also to patient and caregiver groups. Julie, as ASCO's chief medical officer, you've been speaking to stakeholders across the oncology community, as well as many groups that are responding to the crisis. What's your message to ASCO members and patients and caregivers today? Dr. Julie Gralow: Our main message at ASCO to our members, our immediate outreach was, ‘We're thinking of you, we're here for you, let us know how we can help you.' As you've already said, we've learned from past natural disasters. We had Katrina way back when, specifically for the IV drug shortages. We had a shortage back in 2014 due to a problem in Norway, but in 2017 we had another hurricane, Maria, which impacted Puerto Rico and majorly impacted IV fluids. So we have knowledge that we've gained, we as the whole medical community have gained on how to adapt and where we can hydrate orally or, you know, give electrolytes and where we can reserve things. I think one of our main messages at ASCO is that while our members are those who treat patients with cancer, we use IV fluid everywhere in the hospital, the operating room, the emergency room, the ICUs. We are all in this together, and so, while we have some specific things related to oncology where we can probably save fluid and conserve, etc., we need to work as a whole team, a whole body to protect each other. So, if you're developing an incident management team at your institution or whatever, it needs to be multidisciplinary. We all need to be protecting each other's patients as well. Dr. John Sweetenham: Yeah, absolutely. Just briefly on the subject of IV fluids, do you think it will be necessary to mitigate the IV fluid issue by bringing IV fluids in from other countries? Dr. Julie Gralow: I think the full impact, how long this is going to be, how much we can ramp up domestically, is really yet to be seen. all looking at this. So Baxter, which supplies about 60% of hospital IV fluids and peritoneal dialysis solutions, it was flooded essentially at their big plant in North Carolina. They have several other plants in the US and some internationally too. So the question will be, did those other plants also make IV fluids? Can they be ramped up? There are another at least two companies in the U.S. that make IV fluid. What will be their ability to ramp up? we already do. Baxter says they've already; I think Merry Jennifer alluded to this, they've already instituted a mitigation strategy where they're placing products on a protective allocation. So they are really trying to protect against stockpiling, et cetera. The FDA has come out and said it will consider reviewing potential temporary imports. It also is looking at expediting reviews once the manufacturing lines are up and going again, it will expedite those as well. And they're looking at alternative providers. IV drugs are officially on the FDA's drug shortages list, and that allows certain flexibilities, I am told, in terms of, for example, being able to make sterile IV fluids at a local site if it's on the FDA drug shortage list. And there are some other things that go along with it. It's really hard to find on the FDA drug shortage site. You have to use the right keyword. You have to look it up under sodium chloride for injection. You can't look up saline on it. But it is now there. I think it just got placed in the last 24 hours or so. And so that does allow some additional flexibilities. Dr. John Sweetenham: Okay, great. Thank you. So a question for both of you. A couple of years ago, we covered the consequences of Hurricane Ian on this podcast. And Helene and Milton will presumably not be the last storms which are going to disrupt cancer care and undoubtedly cause a great deal of hardship to many people, both our patients and our caregivers, those who are giving care. Climate change probably predicts that this is going to be an ongoing event. You know, these events have undoubtedly tested the disaster preparedness plans of cancer centers in the region. I wonder how you would assess the readiness of cancer centers to respond to these big disasters, which are undoubtedly in our future, and what areas of care do you think would need more attention? Merry Jennifer, maybe I'll start with you for that question. Dr. Merry Jennifer Markham: I think cancer centers, working within their health system, really should have a disaster preparedness plan in place. Here in Florida, I am very used to the preparedness plans that my system has developed really for every hurricane season. And because hurricane season is from June to the end of November, we are fully aware of this plan and can start taking action. And a lot of that deals with when do we close particular clinics? What areas do we need to prioritize? How do we make sure we've got proper staffing? I think that is the type of thing that cancer centers should have really in a written protocol – here's what we do when this news is coming out of the weather center or something along those lines. One of the challenges that we face, and I think probably this is, I guess I'm going to speak for all of the Southeast who is in the, you know, a hurricane, you know, risk area is disaster fatigue. And I think that is a problem. I don't know if it's unrecognized. I fully recognize it because I feel it. think earlier when we were talking, you mentioned Hurricane Ian and I don't even remember, Ian, because we have so many of these hurricanes. Every year there's a new one or multiple, and they all seem to bring the same kind of disasters. Usually on a local scale; I think what we've seen with Helene has just been so massive across multiple states. But the fatigue, that disaster fatigue, I think can lead people to become a little lax. And there is a risk. If we think of all of us as caregivers for all of our patients and for the physicians and teams practicing, it's easy to become numb and tired and worn out of preparing for these disasters. So, I think it's very important that this stays top of mind and that centers are preparing and also cognizant of the fact that fatigue is also a real potential issue. Dr. John Sweetenham: Right, thanks. Julie. Dr. Julie Gralow: We learn from each event and the events have come closer and closer, at least the hurricanes have. I totally agree with Merry Jennifer that we can't have disaster fatigue. Each one does have its unique component. For example, Helene, while we could see the path and it didn't stray that far from its path, did we really expect that this region, this Appalachian region would be the one most impacted? They're nowhere near a coast, you know, it was a bunch of flooding and dams breaking, so each one is different. From ASCO's perspective, we've learned and we've developed both a domestic crisis response team and plan, as well as an international one. And it's, besides hurricanes and major storms, you know, we've had fires and earthquakes and for our international crisis response team, we've been dealing with conflict and getting cancer care delivery in regions of conflict. So by having a team formed, by learning from each event, and then quickly communicating with members when we can get ahold of them on the ground as to what the real situation is and how we can help, I think we've gotten stronger over the years. It's still, with each one, it's horrible for the people on the ground and our job really is to best support our members and their patients as they're trying to get their lives back together. Dr. John Sweetenham: Thank you. So, I think that winds up most of the issues we wanted to cover today. And I wanted to thank you both Dr. Markham and Dr. Gralow for being on the podcast today and sharing your insights on what is, of course, an extremely challenging situation. I should remind listeners that they will find links to disaster resources for providers and patients on the ASCO website at asco.org. You can also follow Dr. Markham on X. Her tag is at @DrMarkham, where she has been sharing key information and resources. And Dr. Julie Gralow will continue to share resources on X. You can find her @jrgralow. We want to wish you, Merry Jennifer, and our many colleagues in the affected regions, all the best during what we know are very challenging times. Dr. Merry Jennifer Markham: Thank you. And thanks to you, Dr. Gralow, for sharing your insights and thoughts with us today as well. Dr. Julie Gralow: Thanks for having us, John. 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 inform. It is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. The guests on this podcast express their own opinions, experience, and conclusions. Guest statements do not necessarily reflect the opinions of ASCO. Mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  Find out more about today's guests: Dr. Merry Jennifer Markham @DrMarkham Dr. Julie Gralow @jrgralow Follow ASCO on social media:  @ASCO on Twitter ASCO on Facebook ASCO on LinkedIn Disclosures: Dr. John Sweetenham No relationships to disclose Dr. Merry Jennifer Markham: Stock and Other Ownership Interests (Immediate Family Member): Pfizer Research Funding (Inst.): AstraZeneca, Merck Dr. Julie Gralow: No relationships to disclose

Dr. Fumiko Chino and Dr. Raymond Osarogiagbon share highlights from the 2024 ASCO Quality Care Symposium, including patient perspectives and compelling research on topics like equity, supportive care, survivorship, and technology and innovation. TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to the ASCO Daily News Podcast. I'm Dr. Fumiko Chino, an assistant professor in radiation oncology at the MD Anderson Cancer Center. On today's episode, we'll be highlighting key research and compelling perspectives that were featured at the 2024 ASCO Quality Care Symposium. I was delighted to serve as the chair-elect of this meeting's program committee, and I'm overjoyed to welcome its chair, Dr. Raymond Osarogiagbon, to the podcast today. He is the chief scientist at the Baptist Memorial Health Care Corporation and the director of the Multidisciplinary Thoracic Oncology Program at the Baptist Cancer Center in Memphis, Tennessee. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for this podcast today. Ray, it's so great to speak with you today. Dr. Raymond Osarogiagbon: Thank you, Dr. Chino, and thank you for letting me call you by your first name. Dr. Fumiko Chino: I think both of our names are complicated enough and so I appreciate the level of familiarity that we've had with each other during the planning process for this fantastic meeting. Now, the Quality Care Symposium featured some really compelling research on very timely topics that address a wide range of issues in cancer care, including quality, safety, equity, supportive care, survivorship, and technology and innovation. Wow, what a lot to cover. Ray, do you mind sharing with me some of the key sessions that really stood out for you? Dr. Raymond Osarogiagbon: Yes, Fumiko, this was such a great conference. Our tagline this year was ‘Driving Solutions, Implementing Change.' We had more than 700 attendees in person and virtually. The Symposium featured many fantastic speakers, oral abstracts, posters, and we had networking opportunities for junior colleagues to interact with leaders in the space. We had conversations that will surely inspire future collaborations to improve quality cancer care. We had patients, advocates. I was inspired by the patient perspectives that were presented, learned a lot. And I really felt like this enhanced our understanding of some of the key issues that we see in our clinics. I was honored to be able to introduce my dear friend, Dr. Ethan Basch from the University of North Carolina, Chapel Hill, who received the Joseph Simone Quality Care Award this year. Dr. Basch gave a talk titled, “On the Verge of a Golden Age in Quality Cancer Care.” In his talk, which received a standing ovation, Dr. Basch tracked his personal development from fellowship training at Memorial Sloan Kettering through a junior faculty position at the same institution under the mentorship of Dr. Deborah Schrag, and ultimately to his current position as chair of oncology at the University of North Carolina and as physician-in-chief at the North Carolina Cancer Hospital. In parallel, with the evolution of the patient-reported outcomes movement that he has been right at the heart of, and also the evolution of cancer care delivery research into its current position of prominence in oncology. That was a spectacular talk, and it rightly received a standing ovation. We also had presentations and panel discussions that addressed patient navigation and cancer care moving from theory to practice, which provided wonderful, diverse perspectives on the evidence-based approaches to patient navigation and cancer care. And a wonderful session on the complexities of the pharmaceutical supply chain and what everyone in oncology should know that looks at the current challenges in the pharmaceutical supply chain. Leveraging technology to support patient-centered multidisciplinary care [was also covered], and we talked about health-related social needs and the impact of diversity, equity and inclusion on the oncology workforce. Patient care perspectives were just incredible. So, Fumiko, as an equity researcher, I really want to hear your key takeaways from some of these discussions. Dr. Fumiko Chino: I have to say, I was so impressed with not just the science that was presented, but also the passion from some of our educational speakers who are really speaking from their expertise and their commitment to try to continue to advance equity in the field of cancer care. And as someone who is still a relatively junior researcher, I feel that the work that I've done over the last decade has really been built on the shoulders of these giants. Just harkening back to you had mentioned that Dr. Basch essentially gave an overview of his career and as a young health services researcher, I've been really impressed about how generous the leaders in the field have been with their time not only to discuss their research at this conference, but also to talk to trainees and fellows and junior researchers and really share the wealth of their knowledge. In terms of equity research presented at the conference though, I was really struck by the overview we were able to provide about the best care to provide to LGBTQ patients. Dr. Mandy Pratt-Chapman actually gave a really lovely overview that was always centered in the patient. It really taught me a lot about what the best practice is to not just collect SOGI data to improve research, but also that there's billing codes that can actually help decrease the chance that a patient may be misbilled based on anatomical misunderstanding of their gender identity. I was very impressed about the capacity for some of our researchers to really think outside of the classic box for DEI research. So not just race as a social construct, ethnicity, but also health literacy barriers. There was a fantastic analysis looking at a randomized control trial (Abstract 385) that actually showed that patients with low health literacy actually got the most benefit from a digital intervention that involved text reminders to increase adherence. And the flip side of health literacy is that we know that the specific interventions that we do really need to be explicitly designed for the populations that they will be implemented on. Dr. LoConte actually had the results from her intervention looking at a radon mitigation indigenous communities (Abstract 44). And I was so impressed about her commitment to the process of listening to the communities and what their needs were, what their concerns were, and then implementing this community led intervention that helped mitigate the radon risk from many households where the actual radon levels were surprisingly high, beyond what they were that what they were anticipating. And so, it's all of these manifestations of how do we actually improve research, how do we advance the field and further the conversation in an era when it seems like DEI is really under attack. Well, I know you've long been an advocate for equity for lung cancer. And I know that you were actually involved in one of the amazing abstracts being presented that was essentially a decade- long QI (quality improvement) project to try to improve standards of care for lung cancer in a high-risk community in the Mississippi Delta (Abstract 278). And it actually showed over time that this surgical pathology intervention actually was able to improve overall survival for lung cancer. I know that this is part of the work that you've been doing for years. Can you talk a little bit about what was presented within the Symposium specifically for lung cancer, including your study? Dr. Raymond Osarogiagbon: Yes, Fumiko. The member of my team, Olawale Akinbobola, who has an MPH that he actually acquired within my research team I'm proud to say, had the wonderful opportunity to present this work on implementing surgical quality improvement, and in parallel, pathology quality improvement in a well-defined population involving 14 hospitals in seven health care systems across five contiguous hospital referral regions in Mississippi, Arkansas, and Tennessee, at the heart of the Mississippi Delta region. So Olawale showed that over the course of four consecutive 5-year time spans, the quality of surgery has improved from a time when using current objective benchmarks of surgical quality, anywhere from 0-5% of resections met these current standards. So basically, applying today's standards, but retrospectively, to where, as the interventions took hold, we now got to a point where about 67% of the sections in this population now attain surgical quality. And we saw in sequential lockstep with that, that the hazard of death among these patients has significantly decreased. All the way, I think using the first 5 years as the reference, the hazard reduced about 64%. Really amazing to see. But you know, there were other fascinating abstracts. There was a randomized controlled trial, Abstract 185, that demonstrated that olanzapine therapy was actually way more effective than prochlorperazine for patients with intractable chemotherapy-induced nausea and vomiting. I found that very compelling abstract. And then there was Elyse Richelle Parks who reported on the effectiveness of a virtual sustained tobacco treatment, Abstract 376 [a clinical trial conducted by ECOG-ACRIN within the NCI Community Oncology Research Program]. This tobacco control intervention is remotely administered using technology that was presented in today's session on leveraging technology to enhance multidisciplinary care delivery.  That too was amazing to behold. Dr. Fumiko Chino: I've been so impressed within my, at least my interactions with the Quality Care Symposium for the last several years about how this meeting really creates the perfect space for this type of science, which can be frankly underappreciated at other meetings. You know, something like a QI project, a quality improvement project leading to an overall survival benefit or a trial like you mentioned, the randomized control trial for olanzapine, which specifically had a quality-of-life endpoint, meaning that patient quality-of-life was a compelling justification for optimal nausea control. These things are really underappreciated sometimes at the larger scientific meetings, and the ASCO Quality Care Symposium is really where these types of studies and this type of research really shines; it's very patient-centered. You mentioned the patient voice being a really integral part, and I certainly agree with that. The entire meeting started with a session featuring a phenomenal patient advocate, Jamil Rivers, who was diagnosed with de novo stage 4 metastatic breast cancer. And her experience with her primary treatment really highlighted some of the care gaps that Black women experience in their journey with breast cancer. And it really charged her to actually create a patient navigation organization to help Black women with breast cancer get more evidence-based care to make sure that they were actually asking the questions that needed to be asked, getting the resources that they qualified for, and making sure they were getting evidence-based care. Now shifting gears a little bit, in oncology and across medicine, there's actually been some major challenges with drug shortages. I'd like to ask you about the session that was featured to inform oncologists about what we need to know about navigating the complexities of the pharmaceutical supply chain. Do you mind sharing highlights from that discussion, Ray? Dr. Raymond Osarogiagbon: I will, Fumiko, but before I do that, I have to follow up on what you said about Jamil Rivers, the breast cancer survivor and advocate who leads the Chrysalis Initiative. She made the statement of the meeting [in my opinion] when she said, “A hospital encounter for a Black woman is like a Black man being pulled over by the police.” Wow. I mean, that's a direct quote. It suddenly helped me understand my wife's many years-long anxiety whenever she has to deal with encounters with clinicians and health care systems. But about that wonderful session on the challenges with the pharmaceutical supply chain. For me, there were two key highlights. One was Dr. Deborah Patt's discussion on the growing influence of pharmacy benefit managers, PBMs, on the cost and delivery of cancer care. And then there is Jason Weston's discussion of how U.S. generic oncology drug manufacturing has moved almost entirely out of the U.S. with this incredible unrealistic price focus, almost so focused on price competition, almost totally ignoring quality and safety. And paradoxically, that fierce competition has inhibited competition, right? So as the margins have shrunk and all these generic drug manufacturers have moved overseas with little oversight, the supply chain gets disrupted because these companies are not able to invest in processes, in their manufacturing facilities and so on. So, when something goes wrong, all of us become vulnerable. And the other striking thing I learned from Jason was this problem is not new. It is not new. It's been with us for decades. And without comprehensive solutions, unfortunately, it's not going to go away. So, these are some of the examples of things that I would really love the podcast audience to go and check out for themselves. Dr. Fumiko Chino: I will just highlight one additional aspect of that session, which was actually the oral abstract (Abstract 1) that was embedded into the session that was specifically about how when during the cisplatin shortage of last year, when that drug was out of stock, which is honestly a very widely available, typically cheap medication, Dr. Jody Garey actually presented on the fact that the things that were substituted were actually far more expensive, and that actually led to not just people not getting the standard of care due to the drug shortages, but also increased costs. So, the bizarre side effect of the race to the bottom in terms of price competition is the fact that during these shortage periods, there's actually a sharp increase in the overall cost, not just to the administration, but also in terms of payer costs and patient cost sharing. So, it is sort of a lose-lose situation. And that was really highlighted to me by that abstract. And I'm so grateful for the research that really puts these experiences that we see in our clinic, things like drug shortages, in a larger perspective of how things like health policy and reimbursement and some of the nitty-gritty that goes on beyond the scenes in terms of oncology practice really is ending up impacting patient care. Now Ray, is there anything else you'd like to highlight before we wrap up the podcast? Dr. Raymond Osarogiagbon: One I maybe should highlight was the discussion about DEI, which is obviously a contentious topic. And we had Dr. Tawana Thomas Johnson with the American Cancer Society tell us how DEI has evolved from something that everybody seemed like they were eager to support and champion in 2020 to a kind of backlash...how we moved from $5 billion in pledges by corporations to support DEI initiatives in 2020 after the George Floyd murder to now where everybody is wanting to roll things back. And yet in the face of this, wanting to roll things back, wanting to respond to the inevitable backlash, there is this commitment still that some companies have had to DEI and workforce development ideas, so nevertheless, ongoing support. For me, that was a bright spot. Dr. Fumiko Chino: I have to say, as someone who started going to the ASCO Quality Care Symposium as a trainee, I've been really encouraged myself in terms of bright spots for this meeting about the engagement from trainees, from medical students to residents and fellows to early faculty. We even had someone who had just graduated high school ask us one of the questions in a session. And that really highlighted for me that this meeting is a very young meeting. It really is the next generation of health services researchers. And that has always been one of the joys about some of the discussions because I feel like the science presented, the education presented is sparking new collaborations, new research paradigms, new mission driven research for another generation. And it's been just simply phenomenal. Dr. Raymond Osarogiagbon: Yeah, the networking opportunities. Wow. It was such a joy to behold people getting together, breaking off in small clusters, interacting with each other, strangers meeting and hitting it off. I mean, just what a wonderful meeting this is. Dr. Fumiko Chino: Yeah, I have to highlight that. Certainly, at my first ASCO Quality meeting at this point, I think eight years ago, I went to one of those Meet the Expert luncheons, had a great conversation with a phenomenal researcher who I still obviously very much admire. And I was sitting at a table at a Meet the Expert luncheon today. And I just felt so invigorated by some of the conversations that I had with the next generation of researchers about how to define their lane, their passion, and how to continue to advance the field. Thank you, Ray, for sharing your key takeaways from the 2024 ASCO Quality Care Symposium and for leading a truly robust program this year. Dr. Raymond Osarogiagbon: Thank you, Fumiko. This has been a labor of love as you will find when you take on this responsibility for next year's meeting. This has been my pleasure. Dr. Fumiko Chino: Thank you so much. I'm really excited about the program that we're going to start planning in Chicago next year. Everyone listening can mark their calendars for October in Chicago. I really want to thank our listeners for your time today. You will find the links to the sessions and the abstracts that we discussed in the transcript of this episode. And 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.   Follow today's speakers: Dr. Fumiko Chino @fumikochino Dr. Raymond Osarogiagbon  @ROsarogiagbon    Follow ASCO on social media:  @ASCO on Twitter  ASCO on Facebook  ASCO on LinkedIn    Disclosures:  Dr. Fumiko Chino: No relationships to disclose Dr. Raymond Osarogiagbon:   Stock and Other Ownership Interests: Lilly, Pfizer, Gillead  Honoraria: Medscape, Biodesix  Consulting or Advisory Role: AstraZeneca, American Cancer Society, Triptych Health Partners, Genetech/Roche, National Cancer Institute, LUNGevity  Patents, Royalties, Other Intellectual Property: 2 US and 1 China patents for lymph node specimen collection kit and metho of pathologic evaluation   Other Relationship: Oncobox Device, Inc.

JCO PO author Dr. Alok A. Khorana, MD, FASCO, Professor of Medicine, Cleveland Clinic and Case Comprehensive Cancer Center, shares insights into the JCO PO article, “Molecular Differences With Therapeutic Implications in Early-Onset Compared With Average-Onset Biliary Tract Cancers.” Host Dr. Rafeh Naqash and Dr. Khorana discuss how multiomic analysis shows higher FGFR2 fusions and immunotherapy marker variations in early-onset biliary cancer. 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 POarticles. 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 joined by Dr. Alok A. Khorana, Professor of Medicine at the Cleveland Clinic and Case Comprehensive Cancer Center, and also the Senior Author of the JCO Precision Oncology article titled, “Molecular Differences With Therapeutic Implications in Early-Onset Compared With Average-Onset Biliary Tract Cancers.”  At the time of this recording, our guest disclosures will be linked in the transcript.  Dr. Khorana, it's an absolute pleasure to have you here today, and welcome to the podcast. Dr. Alok A. Khorana: Thank you. It's an absolute pleasure to be here and thank you for highlighting this article. Dr. Rafeh Naqash: Absolutely. We're going to talk about science, obviously, and a few other things. So to start off, for the sake of our audience, which comprises academicians and community oncologists as well as trainees, can you tell us a little bit about biliary tract cancers, what we have learned over the last decade or so, where the standard of treatment currently lies. And then we can dive into the article that you published. Dr. Alok A. Khorana: As many of you who treat GI cancers know, biliary tract cancers for a long period of time were sort of the orphan cancer in the GI cancer world. They're not nearly as common as, say, pancreatic cancer, and certainly not as common as colorectal cancer. They're sort of also, in this weird ‘no man's land' between well known sort of adjuvant therapy trials in pancreatic cancer or colorectal cancer, but because they're not as high in volume, there weren't really large trials done in this population. What's really changed in the past decade, especially, has been the slow but sure realization that biliary tract cancers are in fact a target rich cancer, almost similar to what you would see with lung cancer, and that's only a slight exaggeration. And in some studies, as many as up to 40% of patients with biliary tract cancers can have something that's targetable. And that's really revolutionized the way we think of biliary tract cancers. It also separated this field from pancreatic cancer where formerly the two used to be lumped together, and even within biliary tract cancers, we are now slowly realizing that there are differences between intrahepatic, extrahepatic and gallbladder cancers. Big change is really afoot in this field, particularly with the identification of mutation directed targets. Dr. Rafeh Naqash: Thank you for that explanation.  Now, another question I have is, although I don't see any GI cancers, but I have good colleagues of mine at our cancer center who see a lot of GI pancreatic/biliary cancers, and one of the things that comes up in our molecular tumor board often is how certain cancers of unknown primary end up being identified or categorized as biliary tract cancers based on NGS. And again, the uptake for these NGS is perhaps isn't optimal in the field yet, but in your practice, how do you approach situations like that? Do you use NGS in certain cases where the tissue of origin or the patterns of the mutations indicate that this might be biliary tract cancer and then treat the patient accordingly?  Dr. Alok A. Khorana: Yeah, that's true. And that's certainly how I approach things, and I would say even in my own personal practice, that has been a change. I was a little bit skeptical about the benefit of sort of tissue of origin type of testing in carcinoma of unknown, primarily, especially if you can sort of narrow it down to one or other area of the GI tract. But with the identification of sort of targeted subpopulations, especially of biliary tract cancer, I think it's become imperative. And I know we're going to get into the paper, but if you want to learn nothing else from this 20, 25 minute podcast, one lesson I just want to make sure everybody gets is that any patient with biliary tract cancer should have NGS done as soon as possible. Dr. Rafeh Naqash: Thank you for highlighting that important aspect.  Now, going to the topic at hand, what was the driving factor? I've heard a lot about colorectal cancers, early onset versus later onset. What was the reason that you looked at biliary tract cancers? Is that something that you've seen on a rise as far as early onset biliary tract cancers is concerned?  Dr. Alok A. Khorana: Yeah. So we got into this subject also from starting out at colorectal cancer. And as you know, and I'm sure most of your audience knows, there's been a lot of literature out there over the past five, six, seven years suggesting and then documenting and then sort of proving and reproving that colorectal cancer is on the rise, and especially in people younger than age 50. And even in that population, it's on the rise in two different subpopulations, people in their 20s and 30s and then people in their 40s that are close to the screening colonoscopy rates. That's been investigated heavily. We still don't fully understand why that's happening, but it's not restricted to the United States. It's a worldwide phenomenon. You can see it in the United States, in North America. You can see it in western Europe, but you can also see it in many Asian countries with specific sort of subpopulations. For instance, in some countries, men are more likely to have early onset cancers.   And then a newer finding that sort of emerged over the past couple of years is that this early onset increase in cancers is not just restricted to colorectal cancer, although that's the one that sticks out the most, but in fact, is widespread across a bunch of different types of cancers. In my own research program, we had gotten into a sort of better understanding of early onset colorectal cancer a couple of years ago, driven primarily by the sort of patients that I saw in my practice. And it's just, as you know, when you have a couple of those heartbreaking cases and they're just impossible to forget, and it sort of just drives your attention, and then you want to do something to help them. And if you can't help them personally, then you want to do something that can change the field so that more of these patients are not coming in your clinic next year or the year after.  So a couple years ago, at the Cleveland Clinic where I practice, we created a center for young onset cancers, and at the time it was primarily focused on colorectal cancer. But as we are getting into colorectal cancer, we realize that beyond colorectal cancer, we are also starting to see more younger people with other cancers, including pancreas cancer, including gastric cancer, and including bile duct cancers. And we realized that because so much attention was being focused on colorectal, that maybe we should also be paying a little bit of attention to what was happening in this space. I want to, for your listeners, point out that the problem in bile duct cancers is not to the same degree as you see in colorectal cancer. Just a couple numbers to sort of, to set this in perspective: about 5%, 7% of bile duct cancers are young onset - it's not a huge proportion - 90%+ percent of patients are not young onset. But the impact on society, the impacts on those providing care, is obviously substantial for younger patients. And it is true that even though the proportion of patients is not that high, the incidence is rising.   And there's a very nice study done a couple of years ago and published that looked at what the cancers are that are rising at the highest rates. And bile duct cancer and gallbladder cancers were listed amongst the two with the highest rate, so about an 8% rate per year of increase. And so that's really what drove our interest was, as we're seeing early onset bile duct cancers, it's rising year by year, and what is this disease? Is it the same as you see in sort of the average patient with bile duct cancer? Is it different? How do we characterize it? How do we understand it? What are some of the causes precipitating it? And so that's what led us to sort of one of the investigations that we've documented in this paper.  Dr. Rafeh Naqash: Excellent.   So, talking about this paper, again, can you describe the kind of data that you use to understand the molecular differences and also look at potential immune signatures, etc., differences between the groups? Dr. Alok A. Khorana: Yeah. So the objective in this paper was to look at genomic differences between early onset and usual onset, or average onset biliary tract cancers. And this sort of followed the paradigm that's already been established for early onset colorectal cancer, where you take a bunch of people with early onset disease, a bunch of patients with average onset or usual onset disease, and then look at the profiling of the tumors. And we've done this for genomics, we've done this for microbiomics, we've done it for metabolomics. And the lessons we've learned in colorectal cancer is that, in many ways, the profiles are actually quite substantially different. And you can almost think of them as diseases of the same organ, but caused by different processes, and therefore leading to different genotypes and phenotypes and microbiomes. We had absorbed that lesson from colorectal cancer, and we wanted to replicate it in this type of cancer.  But as we discussed earlier, this is a relatively rare cancer, not that many cases per year. For colorectal, we could do a single institution or two institution studies. But for this, we realized we needed to reach out to a source of data that would have access to large national data sets. We were happy to collaborate with Caris Life Sciences. Caris, many of you might know, is a provider of genomics data, like many other companies, and they house this data, and they had the age categorization of patients less than 50, more than 50. And so we collaborated with investigators at Caris to look at all the specimens that had come in of bile duct cancers, identified some that were young onset and some that were older onset. It was roughly about 450 patients with the early onset or young onset, and about 5000 patients with usual onset cases. And then we looked at the genomics profiling of these patients. We looked at NGS, whole exome sequencing, whole transcriptome sequencing, and some immunohistochemistry for usual, like PDL-1 and MSI High and things like that. And the purpose was to say, are there differences in molecular profiling of the younger patient versus the older patient? And the short answer is yes, we did find substantial differences, and very crucial for providers treating these patients is that we found a much higher prevalence of FGFR2 fusion. And that's important because, as I'm sure you've heard, there's a ton of new drugs coming out that are targeting specifically FGFR fusion in this and other populations. And hence my statement at the outset saying you've got to get NGS on everybody, because especially younger patients seem to have higher rates of some of these mutations.  Dr. Rafeh Naqash: Excellent. You also looked at the transcriptome, and from what I recollect, you identified that later onset tumors had perhaps more immune favorable tumor microenvironment than the early onset. But on the contrary, you did find that FGFR2 early onset had better survival. So how do you connect the two? Is there an FGFR link, or is there an immune signature link within the FGFR cohort for early onset that could explain the differences? Dr. Alok A. Khorana: Yeah, that's a great question. So, to kind of summarize a couple of these things you talked about. So, one is we looked at these genomic alterations, and, yes, FGFR2 fusion was much more prevalent. It's close to 16% of young onset patients, as opposed to roughly 6% of average onset patients. So almost a threefold increase in FGFR fusion. And because there's so many drugs that are targeting FGFR fusion, and because the population included a period of time when these drugs had already been approved, we think some of the benefit or the improvement in median survival associated with being younger is likely driven by having more FGFR fusion and therefore having more drugs available to treat FGFR fusion related tract cancer with corresponding increase and increase in survival. And that was part of it. There was one other alteration, NIPBL fusion, that's been sort of known to be associated with a certain subtype of cholangiocarcinoma, but it doesn't really have a drug that targets it, so it's not sort of very useful from a clinical perspective.   The other two things you talked about, so transcriptome and immuno oncology markers, we found a couple different results on this. So one is that we found in younger people, angiogenesis was enriched, and why this is so we don't quite have a good answer for that. The other was inflammatory responses. So there's a couple of gamma interferon pathways and a couple other types of pathways that you can sort of do pathway analysis, and we found that those were enriched in the older patients or the average onset patients. But the benefit for immunotherapy was similar across the two groups. So even though we saw these differences in signaling in terms of which pathways are upregulated or downregulated, it didn't seem to translate into the current generation of immune checkpoint inhibitors that we're using in terms of benefit for patients. But we did see those differences.  Dr. Rafeh Naqash: I completely agree, Doctor Khorana. As you mentioned, that one size fits all approach does not necessarily work towards a better, optimal, personalized treatment stratification. So, as we do more and more sequencing and testing for individuals, whether it's early onset cancers or later onset cancers, figuring out what is enriched and which subtype, I think, makes the most sense.   Now, going to the FGFR2 story, as you and most listeners probably already know, FGFR is an approved target, and there are a band of FGFR inhibitors, and there's some interest towards developing specific FGFR2, 3 fusion inhibitors. What has your experience with FGFR inhibitors in the clinic been so far? And what are you personally excited about from an FGFR standpoint, in the drug development space for GI cancers?  Dr. Alok A. Khorana: Yeah, I think the whole FGFR fusion story sort of actually deserves more excitement than it's gotten, and it may be because, as I mentioned earlier, biliary tract cancers are a relatively low volume type of cancer. But the results that we are seeing in the clinic are very impressive. And the results that we are anticipating, based on some ongoing phase two and phase three trials, appear to be even more impressive for the very specific inhibitors that are about to hopefully come out soon.   Also, the possibility of using successive lines of FGFR inhibitors - if one fails, you try a second one; if the second one fails, you try a third one because the mechanisms are subtly different - I think it will take a little while to figure out the exact sequencing and also the sort of the rates of response in people who might previously have been exposed to an FGFR inhibitor. So that data may not be readily available, because right now most patients are going in for longer trials. But having that type of possibility, I think, kind of reminds me of the excitement around CML back when imatinib suddenly became not the only drug and a bunch of other drugs came out, and it's kind of like that. I think again, it's not a very common cancer, but it's really wonderful to see so many options and more options along the way for our patients. Dr. Rafeh Naqash: Thank you. Now, going to your personal story, which is the second part of this conversation, which I think personally, for me, is always very exciting when I try to ask people about their personal journeys. For the sake of the listeners, I can say that when I was a trainee, I used to hear about Dr. Khorana's course, I always thought that Dr. Alok Khorana was a hematologist. My friends corrected me a few years back and said that you're a GI oncologist. Can you tell us about your love for GI oncology and the intersection with hematology thrombosis, which you have had a successful career in also? Can you explain how that came about a little bit? Dr. Alok A. Khorana: Yeah, sure. So it is a common, I guess I shouldn't say misperception, but it's certainly a common perception that I'm a hematologist. But I'll sort of state for the record that I never boarded in hematology. I did do a combined hem-onc fellowship, but only boarded in oncology. So I'm actually not even boarded in hematology. My interest in thrombosis came about- it's one of those things that sort of happen when you're starting out in your career, and things align together in ways that you don't sort of fully understand at the time. And then suddenly, 10 years later, you have sort of a career in this.   But it actually came about because of the intersection of, at the time, angiogenesis and coagulation. And this is the late ‘90s, early two ‘00s, there was a lot of buzz around the fact that many of the factors that are important for coagulation are also pro angiogenic and many factors that are coagulation inhibitors. These are naturally occurring molecules in your body, and can be anticoagulant and anti angiogenic. A great example of this is tissue factor, which is, as you'll remember from the coagulation pathways, the number one molecule that starts off the whole process. But less widely appreciated is the fact that nearly every malignancy expresses tissue factor on its cell surface. This includes breast cancer, it includes leukemia cells, it includes pancreatic cancer. In some cancers, like pancreatic cancer, we've even shown that you can detect it in the blood circulation. And so for me, as a GI oncologist who was seeing a lot of patients get blood clots, it was particularly fascinating to sort of see this intersection and try and understand what is this interaction between the coagulation and angiogenic cascades that's so vital for cancers. Why is coagulation always upregulated in cancer patients? Not all of them get blood clots, but subclinical activation of coagulation always exists. So I would say I was fascinated by it as an intellectual question and really approached it from an oncology perspective and not a hematology perspective.   But then as I got deeper into it, I realized not everybody's getting blood clots, and how can I better predict which patients will get blood clots. And so I had both a hematology mentor, Charlie Francis, and an oncology mentor, Gary Lyman. And using sort of both their expertise, I drafted a K23 career development award specifically to identify predictors of blood clots in cancer patients. And that's the multivariate model that later became known as the Khorana Score. So again, I approach it from an oncology perspective, not a hematology perspective, but really a fascinating and still, I would say an understudied subject is why are cancer patients having so many clotting problems? And what does it say about the way cancer develops biologically that requires activation of the coagulation system across all of these different cancers? And I think we still don't fully understand the breadth of that. Dr. Rafeh Naqash: Very intriguing how you connected two and two and made it a unique success story. And I completely agree with you on the tissue factor. Now there's ADCs antibody drug conjugates that target tissue factor, both a prude as well as upcoming.   Now, the second part of my question is on your personal journey, and I know you've talked about it on social media previously, at least I've seen it on social media, about your interactions with your uncle, Dr. Har Gobind Khorana, who was a Nobel Prize winner in medicine and physiology for his work on DNA. Could you tell us about how that perhaps shaped some of your personal journey and then how you continued, and then also some personal advice for junior faculty trainees as they proceed towards a successful career of their own? Dr. Alok A. Khorana: Yeah, thank you for bringing that up. So very briefly, this is about my uncle. He's actually my great uncle. So he's my grandfather's youngest brother. And I grew up in India in the ‘70s and ‘80s, and at the time, I ran away from this association as fast as I could, because growing up in India in the 70s and ‘80s, it was a socialist economy. There wasn't a lot going on. There was certainly none of the IT industry and all of everything that you see right now. And so there were very few icons, and my great uncle was definitely one of those few icons. As soon as you mentioned your last name, that would sort of be the first question people would ask. But he did serve as a role model, I think, both to my father, who was also a physician scientist and a professor of medicine, and then to myself in sort of making me realize, one, that you can't really separate medicine from science. I think those are really integrated, and we want to ask questions and answer questions in a scientific manner. He chose to do it in a basic science world. My father did it in a clinical science world, and I have done it in a clinical and a translational science world. Again, sort of using science as the underpinning for sort of understanding diseases, I think, is key. And so that was certainly a massive inspiration to me.  And then after I immigrated to the US in the late ‘90s, I met him on a regular basis. He was certainly very inspirational in his successes, and I realized the breadth of what he had done, which I did not realize in my youth growing up. But this is a person who came to the US. This was before Asian immigration was even legal. So he got here and they had to pass a special bill in Congress to let him be a citizen that was based on the sort of work that he had done in Canada and in the UK before he came here. And then he sets up shop in the University of Wisconsin in Madison and hires tons of these postdocs and essentially converted his lab into this massive factory, trying to figure out the genetic code. Really just the type of dedication that that needs and the amount of work that that needs and the ability to do that in a setting far removed from where he grew up, I think it's just really quite mind boggling.  And then he didn't stop there. He got the Nobel for that, but I have these letters that he wrote after he got the Nobel Prize, and he was just completely obsessed with the possibility that getting the Nobel would make him sort of lose his mojo and he wouldn't be as focused on the next aspects of science. And he was just really dedicated to synthesizing DNA in the lab, so creating artificial DNA, which he ended up doing. And the offshoot of that work, so not just the genetic code, but PCR essentially was developed by his lab before it became sort of what we now know as PCR. And then ditches all of that in the ‘80s and ‘90s and moves to understanding the retina and just focuses on retinal disorders. And then signal transduction, essentially trying to figure out when a single photon of light hits your eye, what happens biologically. It's a completely different field. And just took that on and spent the next 20,30 years of his life doing that. So the ability to sort of change fields, I thought that was very inspirational as well, that you don't have to just stick to one question. You can get into one question, answer it as much as possible, and then find something else that's really interesting to you and that really grabs your attention, and then stick with that for the next couple of decades. So lots to learn there. Dr. Rafeh Naqash: Thank you. Thank you. And then, based on some of your personal lessons, what's your advice for junior faculty and trainees as you've progressed in your career?  Dr. Alok A. Khorana: I think, number one, and I can't emphasize this enough, and sometimes it actually causes a little bit of anxiety, but it is finding the right mentor. And for me, certainly that was key, because my mentor, who was Charlie Francis, was not an oncologist who was a hematologist, but was like me, sort of supported this idea of trying to understand, hey, why does coagulation interact with cancer? And so he approached it from a hematology perspective, I approached it from a cancer perspective, but he sort of gave me the freedom to ask those questions in his lab and then later on in the clinical setting and clinical translational setting, and then got me access to other people who are experts in the field and introducing you and then getting you on committees and making sure you sort of get into clinical trials and so on. And so having a mentor who sort of supports you but doesn't stifle you, and that's really key because you don't want to just ask the question that the mentor is interested in. And as a mentor now, I don't want to have my mentee ask the question that I'm interested in, but also a question that the mentee is interested in. And so there's a little bit of a chemistry there that's not always replicable, and it can go wrong in sort of five different ways, but when it goes right, it's really vital. And I mentioned it causes anxiety because, of course, not every day is great with your mentor or with your mentee, but over a period of time, has this person done sort of their best to get your career off to a start? And have you served that mentor well by doing the things that are– there's responsibilities on both sides, on both on the mentor and on the mentee. And if you can find that relationship where there's a little bit of chemistry there and both of you are effectively discharging both your responsibilities and satisfying your intellectual curiosity, I think that can't be beat, honestly. To me, sort of number one is that and everything else follows from that. So, the networking, making sure your time is sort of allocated appropriately, fighting with sort of the higher ups to make sure that you're not having to do too much, things that are sort of away from your research interests, all of that sort of flows from having the right person. Dr. Rafeh Naqash: Couldn't agree with you more, Dr. Khorana, thank you so much. It was an absolute pleasure. Thank you for sharing with us the science, the personal as well as the professional journey that you had. And hopefully, when you have the next Khorana Score, Khorana score 2.0, JCO Precision Oncology will become the home for that paper and we'll try to have you again maybe in the near future.  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. Thank you so much.   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.   Disclosures: Dr. Khorana  - Honoraria Company: Pfizer, Bayer,  Anthos, Sanofi, BMS, WebMD/MedscapeConsulting or Advisory Role Company: Janssen, Bayer, Anthos, Pfizer, Sanofi, BMS Research Funding Company: Anthos, Bristol-Myers,  Squibb Travel, Accommodations, Expenses Company: Janssen, Bayer, Bristol-Myers Squibb 

Navigating the Journey of Fatherhood Fatherhood is a complex and rewarding journey that demands a unique balance of strength, empathy, and patience. For fathers of daughters, the stakes can feel particularly high. In a recent episode of the Dads with Daughters podcast, hosts Dr. Christopher Lewis, Michael Ramos, and Steven Manchester delve into the nuances of raising daughters, from the initial trepidation to the ongoing quest to raise strong, independent women. Embracing the Journey Together Dr. Christopher Lewis opens the episode by emphasizing the importance of community and learning from one another's experiences. "All of our journeys is a little bit different," he notes, "we can learn from each other... as long as you're willing to open yourself up to learning." This sentiment sets the stage for an enlightening conversation with guests who have both navigated this journey and sought to share their wisdom with others. The Initial Fear and Responsibility When asked about their first reactions to learning they were going to be fathers to daughters, both Steven Manchester and Michael Ramos admit to feelings of terror. Such an emotional response is not uncommon; many fathers experience fear when anticipating the responsibilities of raising a daughter. Manchester explains, "I needed to do it the right way... kids don't necessarily listen, but they do watch." Ramos, reflecting on his own experience, highlights the ongoing nature of parenthood: "I just had a little baby girl and I brought her home from the hospital... I was going to learn every single day and never stop learning." Addressing the Biggest Fears Lewis probes deeper, asking about their biggest fears. Here, Manchester articulates the weight of setting a high standard, "I want me to be the example of what she should expect." For Ramos, the sentiment is similar. He emphasizes the importance of modeling respectful behavior to set high expectations for how his daughters should be treated by others, and also how his sons should treat others. Overcoming Challenges Every parent faces challenges, but raising daughters comes with its own unique set of difficulties. Manchester likens raising boys to "playing checkers" and raising daughters to "playing chess." The complexity, he notes, requires a deeper level of empathy and understanding. Ramos concurs, describing the intricate personalities of his daughters and the importance of adapting his approach to meet each of their unique needs. Building Strong, Unique Relationships Fostering strong relationships with daughters involves more than just being present; it requires emotional vulnerability and genuine connection. Ramos shares that learning to be nurturing, sensitive, and empathetic was crucial for forging these bonds. Manchester underscores the importance of having individual relationships with each child, independent of the rest of the family. The Genesis of "The Dad Bag" The conversation then shifts to the inspiration behind The Dad Bag, a book co-authored by Manchester and Ramos. From the anxious moments of early fatherhood to the realization that parenting lacks an instruction manual, Ramos recounts his journey towards writing a guide that offered practical, heartfelt advice for new fathers. Manchester, an accomplished author, saw an opportunity to create something impactful, noting, "This book has the potential to have more of a positive impact than most of the stuff that I've written." Lessons from The Dad Bag The Dad Bag uses the metaphor of a "dad bag" filled with symbolic items to represent life lessons. These items serve as visual aids to reinforce critical messages, making the lessons accessible and memorable for both the father and child. The book aims to break through stereotypes and offer a new model of fatherhood defined by empathy, vulnerability, and engagement. Be There and Don't Give Up As the podcast concludes, Dr. Lewis asks for their final piece of advice to fathers. Manchester succinctly states, "Be there," while Ramos elaborates, “Don't give up. You got this." Their words resonate as a reminder that fatherhood is a journey filled with highs and lows, but with presence and perseverance, every dad can make a profound impact on their daughters' lives. For more insights and to get your copy of *The Dad Bag*, visit [Amazon](https://www.amazon.com). Fatherhood is a journey best taken together, learning and growing every step of the way. Here's to raising strong, independent women, one day at a time.   TRANSCRIPT Dr. Christopher Lewis [00:00:01]: Welcome back to the dads with daughters podcast, where we bring you guys to be active participants in your daughter's lives, raising them to be strong, independent women, Really excited to have you back again this week. As always every week, I love being on this journey with you, an opportunity to be able to welcome alongside you as you're working to raise those strong independent women that you want to grow up in society today. And all of our journeys is a little bit different. We're all on a unique journey, but we can learn from each other. We have an opportunity to learn from each other. And every day that we walk on this journey, there's something new that we can learn from the person next door, from the person on the other side of the earphones. It doesn't matter as long as you're willing to open yourself up to learning. And that's what's important. Dr. Christopher Lewis [00:00:50]: And every week I work to be able to help you to meet new people, fathers or others with resources, people that can help you to be able to see fatherhood in a little bit different way. Every father fathers in a little bit different way. And there's a lot of resources that are out there as well. Today, we've got 2 great dads with us. Steven Manchester and Michael Ramos is with us today. They both are fathers of 4. We're gonna be talking about their journey as fathers, but also authors. We're gonna be talking about a book that they put out just recently called The Dad Bag, and we're gonna be talking about that as well. Dr. Christopher Lewis [00:01:27]: So I'm really excited to have them here today and have you learn from their journeys. Steven, Michael, thanks so much for being here today. Steven Manchester [00:01:33]: Thanks for having us, Chris. Michael Ramos [00:01:34]: Thank you very much, Chris. Dr. Christopher Lewis [00:01:35]: It is my pleasure having you here today. And first and foremost, I wanna turn the clock back in time because I have that power and I love to be able to have our dads do some self reflection here. And I wanna go back to that first moment that you found out that you were gonna be a father to a daughter. What was going through your heads? Steven Manchester [00:01:52]: Tara. Absolutely, Tara. I think for me, Chris, it was a lot of weight. Right? Because I needed to do it the right way. And we've, you know, as you know, and Mike knows clearly, kids don't necessarily listen, but they do watch. So from the moment we had our daughter, Isabella, I can honestly say she's made me a better person, a better man. And I've been really conscious of what I've done and the things I've said because of wanting to be that dad to her. Michael Ramos [00:02:13]: I think Steve probably echoed my exact sentiments with Tara, uncertainty. I know I figured it out. I I knew I'd figure it out eventually, and some things would be innate, but there were so many questions that I didn't have. And I think the answer is that I didn't have to questions. And I won't tell you where the dad bag came from yet, but it does directly connect to the moment that I realized, like, I just had a little baby girl and I brought her home from the the hospital. But I think I learned within the first few months that this was a journey and not a destination being a dad, specifically to girls, that I was going to learn every single day and never stop learning because things would always change. And that's exactly what has happened and continues to happen, even with the oldest one being 19. Dr. Christopher Lewis [00:02:58]: Now, both of you said that your first reactions were terror. And that being said, I hear that from a lot of dads, especially dads with daughters, that there is fear, the fear going along with raising daughters. Talk to me about your biggest fear in raising a daughter. Steven Manchester [00:03:12]: It's my true belief that our job is to to raise them, right? Not keep them. So even from the time that they're young, again, it's all about setting that example, but whoever she ends up with or whoever she has contact with as far as boys or men, I want me to be the example of what she should expect, right? Like the bar should be raised very high. So for me, the tarot really comes from the weight of responsibility, right? Of getting it right. You know what I mean? And it's never gonna be perfect, we all know that. God knows I've made my fair share of mistakes, but the intentions of being conscious of the fact that listen, I need to do the best I can do so that she understands what, you know, what she deserves. Right? Michael Ramos [00:03:56]: And I think for me, it was very much the same. It's funny because I tell the story and it it applies to both my boys my boy and my girls. But, as far as Steve said, setting the bar. I always wanted my girls to know what the expectation was from the boys that would they would come in contact with. And then I wanted to be the same example for my son so he would know how to treat all of the people, and lead by example in that way. And and somebody had once shared a story, and that's where I learned this from. They shared a story once with me and they said, I want if my daughter goes out on her 1st date at whatever age it is and somebody treats her disrespectfully, I want it to be a red flag. I don't want it to be something that feels normal or feels like she's seen or experienced at home. Michael Ramos [00:04:48]: So although I think that's who I am anyways, is to be very respectful at all times. It especially made me conscious of the fact that I need to be respectful at all times in my treatment of all women, whether it was a partner, a mother, a grandmother, a sister, because that's the example that I was setting for them. Dr. Christopher Lewis [00:05:04]: And raising kids is never easy. There is definitely high points, but there is challenges, there's hard parts. Talk to me about the hardest part in raising a daughter. Steven Manchester [00:05:14]: Well, I can tell you from experience, you know, I've raised a couple sons and that was like playing checkers. And then along comes my girl and now I'm playing chess at an advanced level. So it's amazing. I mean, you almost have to become an empath in a sense where it's not just the way that you think, it's the way that you feel and trying to understand how they feel and and providing what they need. So for me, the hard part was, I guess, getting out of my way and not trying to fix everything for her. Just being able to listen and just be there for her. Michael Ramos [00:05:40]: Again, similar. It was being able to determine when I needed to listen and when I needed to solve the problem because they're very different and there will never be any instruction given. There's almost an expectation that and I said because I've had hundreds of conversations with my 2 teenage daughters where sometimes I got it right and sometimes I was listening when I should have been solving and sometimes I was solving when I should have been listening. And I think to answer the question more specifically, what's been the most difficult part for me, I think has has been learning their personalities because I feel like they're a little more deeper and complex than my boy, and I can only draw from that example. But my 3 daughters are all very different from each other. And there's an expression in psychology that they use where you peel the layers of the onion back to get what's inside, to get to what, you know, the deep root of what's inside is. And one daughter wants me to peel the onion very, very slowly over the course of 45 minutes to get to that. The other daughter wants me to smash the onion, which is more my style. Michael Ramos [00:06:45]: Get what's inside. And then the other one wants me to peel it, like, ever so slowly, then start smashing the load, then go back to peeling. You know, so I think that's been the most difficult part is trying to understand how complex and beautiful their personalities are, how unique they are, and then how I need to then respond differently, learn and grow and do things that don't feel natural to me because my personality tells me to handle everything one way, but they are very different human beings and need me to handle things differently. Dr. Christopher Lewis [00:07:11]: Now you talk about the fact that every child is unique, and that's definitely the case. You can have 2 kids that you come from the same parents, and they can be completely different individuals, and we always see that. So talk to me about with your kids, especially your daughters, how have you been able to build those strong, unique relationships with each of your daughters? And what's your favorite thing that you do and share with your daughters? Michael Ramos [00:07:42]: So important to me. I think learning that it was okay to be nurturing, learning that it was okay to be sensitive, learning that it was okay to cry. And I'm not saying breakdown crying every 15 minutes throughout the day, but learning that it was okay for me to have emotions because society has dictated to me that I can only be tough, that men don't cry and that men don't have emotions and reactions like that. So I was able to connect with my daughters because I was able to be vulnerable. I was able to connect with my daughters because I knew empathy, because if I didn't know empathy, how could I understand them and be compassionate and be empathetic if I couldn't be that myself? So through a 13 week curriculum that I became a nurturing father's facilitator and worked with a lot of dads and some incarcerated dads. I learned a lot of things that later on in life where I was I was able to, to apply. But I think those things were so critical in order for me to be able to connect with them at the level that that I do where they're so comfortable. They'll talk to me about literally anything. Steven Manchester [00:08:42]: That's not gonna be easy to follow, Chris. That was fantastic. But I will just add to that and say that for me and Bella, it was just 1st and foremost just being there, making sure that she knows that I'm a vet. I don't care what it is like I'm there. And secondly, I think it's so important to have relationships with each of your kids that are independent of everybody else in the family. So there are times the whole family is doing things, and then there's times where I just go out to to lunch with my daughter. And then we talk about and it's a a relationship that I've established just between her and I, and I think that's where the trust is born and it's kind of built on. I don't ever want her to play, you know, need to feel like she used to play favorites, but it's, it's also, it's very, very important to me if you're feeling down, you'll just need to go to your mother. Steven Manchester [00:09:23]: You can come to me as well. And to Mike's point, being aware of the fact that I need to have that empathy, I need to show that empathy, and And I may not have all the answers. And even if I do, she probably doesn't wanna hear them anyway. So again, it's just being available and and, making sure she knows that I have her back, which is an odd way to put it. Dr. Christopher Lewis [00:09:42]: But Now I mentioned at the beginning that the 2 of you came together to write a newer book called dad bag or the dad bag. And, I guess I wanna go back before I ask you some questions about the book itself. Let's go back to the genesis of this because I know, Steve, you've been an author for many years, your style of writing is a bit different than what this is. So so talk to me about how the 2 of you came together and why you decided to come up with this concept and put it onto paper. Michael Ramos [00:10:12]: So, let me just stop by saying I just need to give a little kudos to the amazing human being, father, and friend that Steve is because Steve Manchester, I've known as an author and I've known as a friend. I don't consider myself to be an author. This was something very important to me, and he's done presentations for me and in front of dad's groups and for private agency and also some state agencies. So I knew that he would be the perfect person. Where it came from was early, you asked, the terror feeling of knowing that I was having a little girl, but also just like a child, period. I remember bringing my daughter home from the hospital and putting her on the floor in the car seat. And I was sitting in the living room by myself, and I looked down at her in the car seat, sitting there between my legs. And I said, geez, what do I do now? And I went, well, I guess I should take her out. Michael Ramos [00:10:58]: That's a stop. Let me take her out of the car seat. And I mean, I kinda knew what to do, but, like, I also didn't. So I figured it out, stumbled along over the next, like, you know, week or 2, and then the remote control broke for the TV. So I went to RadioShack for anybody under 40 who's listening. That's, an electronics saw that once was in business. But I went to RadioShack and I bought a new new remote control for the TV. I brought it home and I opened it up. Michael Ramos [00:11:27]: It was like $6.99, and it had 12 pages of instructions in 5 different languages. And I said, this remote control comes with that many pages of instructions in so many different languages. And I just brought a beautiful little human being home from the hospital with, like, no directions whatsoever, with no instruction, with no anything. And I said, gee, someone should write a book, not only just for parents to come home from, like, you know, the the hospital with, but especially dads. And that's where the dad bag came from. Steve and I had already worked together doing some fatherhood work, him mostly doing some presentations. And I was already doing nurturing fathers and also some a lot of presentations nationally. And I reached out to him and just just like that, he said, love it. Michael Ramos [00:12:14]: Love the idea. Let's do it. And I know that fatherhood is so important to him. I knew it just would be a great marriage to, get the book written. Steven Manchester [00:12:22]: I gotta tell you, it was a no brainer for me because first and foremost, I really admire Mike. The things that he's done in the community, for the state, the impact that he's had on people, how can you not get your wagon to that? So some of the themes that I've had in my writing over the last 30 years really has a lot to do with fatherhood. Mike and I are really big on there's a big difference between being a father and being a dad, and it's like kinda hammering that stuff home. I also have a background in the prison system. I worked for the Department of Correction for 10 years. So I saw guys that were leaving without a clue on how to father their children. And you think, what a tragedy, right? Because generationally, that's, you know, that's potentially, you know, absolutely awful, right? So, it made perfect sense. And when we got together Mike's concepts, we were able to flesh them out. Steven Manchester [00:13:04]: It took some time. We had to find the right illustrator in Stephanie Grassi, who's just a wonderful person as well. So this hasn't been any work at all. For me, it's been a joy. And I really think, I mean, I normally write adult novels, write 90,000 words. This book, I don't know what even it came in at, but I think this book has the potential to have more of a positive impact than most of the stuff that I've written. And I I'm grateful to Mike for that opportunity to be able to be a part of Michael Ramos [00:13:29]: it. Ironic. I'm more grateful to you. So that's really nice. Steven Manchester [00:13:33]: And I I do mean that sincerely, right, for the people that are listening. I think, you know, Michael will get into this a little bit too, but it's not a bad bag, but it's really I think it's for the family. I think it's for the entire family. I think it's for the dad kind of being able to help mom out or step up and and, you know, do what he's supposed to do. But in a way that what I love about this is it's really almost an instruction guide that's disguised as a children's book. So if dad's reading that to to, you know, his child and dad's also learning as well. Right? And I'm a firm believer we're all in the same boat. Right? It's just you gotta pick up a paddle and start rowing, and I think that's what this book's about. Michael Ramos [00:14:08]: There's so much data and statistics out there that prove that mom's health is increased significantly when dads are engaged. There's factors and indicators for breastfeeding that more moms breastfeed and are likely to breastfeed if they have dads engaged. And it makes sense why. And it makes sense that there's moms that are under less stress when dads are involved because dads are helping out. And we know parenting for mom or dad, because both are critically important, is very difficult if you're doing it alone. I mean, I think that's also one the things that we like to drive home is that dads really need to be engaged and involved. And the difference between being a dad and being a father is exactly that. It's not just buying a ball for your kid and saying, oh, here, I bought this ball for you. Michael Ramos [00:14:49]: And then going in the house, it's stopping to teach the rules, to play the game, to, you know, to teach kids how to self regulate. It's all of those things. And while you're doing that, mom gets a break too and vice versa. Dr. Christopher Lewis [00:15:02]: Now in the book, one of the things that I noticed was that the father in the story talks about the importance of effective communication. How do you think his approach to communication differs from the conventional methods and why do you think it's effective? Michael Ramos [00:15:18]: I think it's because mostly what I was saying before about empathy and compassion and being able to look at the communication from a different perspective and not from the more conventional model. And although I I think there's been a lot of movement more recently with lots of men in this country and lots of dads. I still think there's a lot of dads that still believe that they are the disciplinary, that they shouldn't cry, that they shouldn't have emotion, that they are supposed to be strong and tough. And you can be those things too, but you can also have compassion, be empathetic, and be an engaged dad. It'd be nurturing. And I think that's the difference in the approach. That's the difference in the patience. That's probably a keyword there. Michael Ramos [00:16:02]: The patience that it takes to develop those relationships and understand that with 3 daughters, the dad in the book was specifically just the boy and the girl, but the dad in the book's ability to understand and that that's what it took in order to connect with the children and was that a level of patience to really understand them and be able to see that empathy and that compassion. Steven Manchester [00:16:24]: For me, like the communication, this book in many respects is, I think we're trying to break through some stereotypes. And when you look at a generation just prior to us, my father and his brothers and my grandparents, and it went from you to be seen and not heard to my father would listen, but empathy, I'm not sure, was at the top of the list. He was putting food on the table, shoes on your feet, and if you cry, then he didn't care for it. So for me, and I'm gonna just switch real quickly right to my sons. If my sons fell down and scraped their knee, I don't I don't want anybody crying. Right? We we talked about that. But if there's something that really hurt them and it hurt their soul, I'll sit and cry with them. And it was so, so important, like, when my parents passed, I watched my kids watching me and I didn't hold back. Steven Manchester [00:17:05]: And I also talked about it. So Mike brought up the word earlier, vulnerable, and I think that's the key here. I believe some men see things as weakness, right, when they show their feelings. For me, that's true strength. I mean, that's strength to be able to show your children, I also have feelings, I also mourn and grieve and, you know, I'm happy and I'm sad. By sharing that with your children, you also give them permission to do the same. And I think it just bonds you closer. Right? My kids are more apt to come to me because I'm not going to judge them based on their emotional reaction. Steven Manchester [00:17:33]: And I think that's one of the things I really love about this book. And Mike's concepts, even, you know, very early on from boys playing with a doll or girls asking questions, like, for me, it was like kinda let's let's just break through that and be honest. Just be vulnerable and honest. And and I think that's where the magic is in this book. Michael Ramos [00:17:49]: You know, to expand a little bit on what Steve said with a slightly different concept, it also makes me feel strong to be able to care for my my children. So, yeah, it's a it's a sign of strength, like like Steve said, to be able to be vulnerable and to be able to give your children permission to feel those feelings too. But it also makes me feel strong to change a diaper and to be able to cook food and to be able to care for my children and nurture my children because culturally and also generationally, historically in my family, that's not something that men do. Men don't change diapers. Men don't wash clothes, do laundry. They don't do any of those things. I've always seen that as a sign of weakness. It makes me feel strong to know that I can take care of myself and my children at all times if I need to. Michael Ramos [00:18:31]: It feels completely opposite to me if I have to rely on someone else to do those things because I I'm just not or I don't know how. So also, I think that's to answer your question too a little bit, that's probably a less conventional approach, but I think that's changing and I'm very happy that that's changing. Dr. Christopher Lewis [00:18:46]: I noticed also in the book that the book is called The Dad Bag. The father uses various items from his dad bag as symbolic representations of life lessons. Can you discuss the significance of the metaphor that you're using here and how it adds depth to the narrative? Steven Manchester [00:19:03]: I think this is very intentional, right, right from the beginning that we were gonna use a backpack called the dad bag, much like a mom would have a diaper bag. The dad has the because this book was written really for for families and and children from, you know, because this book was written really for families and children from 5, you know, 5 years old on. So to look at visuals and then hear the narrative that goes along with it, I think it helps the dad or the protagonist within the story, as well as the dad who's reading the book, you know, to to his child, right? Whether it be a boy or a girl. For me, it's just again, I think kids are very visual and I think it helps to carry those lessons. It's easy to remind a kid, if you're talking to them about a certain lesson in years and a prop, later on, all you have to do is pull up the prop, and the message has been received again. Michael Ramos [00:19:50]: I love the representation of each item, and I feel like there could be a 1,000 things in every dad bag because of all the the life lessons, but that's where the onion peeling, that's a very personal family specific story with one of my daughters. We've we've talked about this. She'll actually reference it and say, papa, I need you to peel the onion. So we use that. It's a metaphor and it's something that, you know, you way of addressing and and introducing something in the book, but it it comes from draws from a an an actual experience that's really helped with communication that's been used a number of times where one daughter will say, you could just bust the onion because, like like, I'm going out tonight. Like, my friends are picking up in 10 minutes. You know what I mean? Or they'll say, I'm a you could just bust that onion open. So with that, everybody that ends up buying, I'm gonna send onions to everyone. Michael Ramos [00:20:39]: No. Nobody's getting onions. I'm just I'm just kidding. Dr. Christopher Lewis [00:20:42]: Now I'm not gonna give up the end of the book, but I will say that the father at the end does share a heart felt letter that he wrote to his kids before they're born. How do you think this letter really encapsulated or encapsulates the father's hopes and aspirations for his children's future? Steven Manchester [00:20:59]: I think it's a representation of the responsibility that he feels. I think the important piece here, Chris, is that he wrote it before that child was born. So to Mike's earlier point, it's so important to learn each of their personalities and to be able to almost retrofit how you father, right, or how you parent. What I like about that piece of the book is that he wrote it from his heart before this child was born, right? So these are his aspirations, his dreams, and also the responsibility he feels, right, to be the right dad for this kid. And in Dr. Christopher Lewis [00:21:25]: the end, as people are reading this book, as they are reading it to their own kids, what are you hoping that the fathers that are reading this are gaining from it personally? And what are you hoping that their families gain from it? Michael Ramos [00:21:39]: I'm hoping that at the very, very least, just a sliver, if the dad learns or a light turns on that there is more than one way and that there's a possibility to think outside of the box and it helps him have less fear, not have that terrified feeling. And that's why the goal for me is to have this this book literally in every single hospital in the country. Because for me, it doesn't make sense that any dad should ever leave the maternity ward of a hospital with a human being without having this book in their hand because it exists. And because it's an instructional manual, it just makes sense to me because then dads don't have to be afraid. Dads won't buy remote control that have more instructions than their child's will have that they will have brought their child to him from the hospital and it'll help with that fear. And that's what I hope the dad gets from it. And if the dad gets that, the family gets everything. So I don't even need to say what the family will get from it because if the dad, they all win. Steven Manchester [00:22:31]: That's a great answer. For me, I get, you know, I I've read this book 7000 times. Right? So you get to the end of it. It's almost like a sub, like a subtle contract, right, between the father and his child, where it's like, I'm setting some expectations for you, but really what's happening is he's setting expectations for himself. He's kinda laying it out there for his daughter or his son. So I love that piece of it. We don't use a sledgehammer to, you know, slam people over the head with it, but dad legitimately sits down and reads this to his daughter, then there are some expectations that are there. And so to to Mike's point, right, some of the fear hopefully gets dispelled and and this dad understands stands. Steven Manchester [00:23:05]: He's not the only one in the boat. We got a lot of people in the boat, so stop rowing. Mike's tying. Dr. Christopher Lewis [00:23:09]: And now we always finish our interviews with what I like to call our fatherhood 5, where I ask you 5 more questions to delve deeper into you as dads. So I'm gonna ask you both. So first and foremost, in one word, what is fatherhood? Love. Steven Manchester [00:23:21]: I'm gonna say commitment because you use love. Dr. Christopher Lewis [00:23:24]: Now when was the time that you felt that you finally succeeded at being a father to a daughter? Steven Manchester [00:23:31]: Never. I'll say the same. I can't use one word, but it still hasn't happened. And I'm not sure it will until I draw my last breath. Dr. Christopher Lewis [00:23:37]: Now, if I was to talk to your kids, how would they describe you as a dad? Michael Ramos [00:23:41]: I would say loving. It depends on the kids. I hear cool a lot, but that's I sing in a rock band, and I have lots of tattoos. So, like, to daughters, I'm like a really cool dad. There's a lot of words, but I do hear cool a lot. Like, I'm a cool dad. Dr. Christopher Lewis [00:23:55]: Now who inspires you to be a better dad? Steven Manchester [00:23:57]: I would say the kids. I would say each one of my children because I owe that to them. Michael Ramos [00:24:01]: Everything that was missing in my life from a father. Dr. Christopher Lewis [00:24:05]: Now you've both given a lot of pieces of advice today, things that you shared in the book, but also things that you've learned in your own journeys. As we finish up today, what's one piece of advice you'd want to give to every dad? Steven Manchester [00:24:18]: For me, it's 2 words, be there. Above all things, just be there. Michael Ramos [00:24:22]: I'd add on to it. Don't give up. You got this because I think that's what I've learned from working with so many dads over the past 15 years or so is that a lot of dads just give up or they don't feel like they're good enough. And if they can't be perfect, then they don't wanna let their kids down. So that's why they check out and that's why they're not engaged. And they're not there, like Steve's saying, to be there. Don't give up on yourself. You got this. Michael Ramos [00:24:44]: And, yes, be there. It'll all come. And make the mistakes. It's okay to make the mistakes. We all do. That's called being human. It has nothing to do with being a father. It has to do with being you. Dr. Christopher Lewis [00:24:53]: Now if people wanna find out more about the book or about either of you, where should they go? Steven Manchester [00:24:57]: First and foremost, amazon.com would be the first place that they can go to. So the book's available as an ebook. So we you have the electronic version and it's also print. It's done in print as well. And we have some I don't think it's something we'll talk about today, but we have some big plans for this book to introduce to the masses. And the hope is, again, to Mike's point, whether it be hospitals, prisons, to get this book out in mass where we can make as much impact as possible. Dr. Christopher Lewis [00:25:27]: A stories, your journey today. I truly appreciate you being here, for sharing your voice, and I wish you both the best. Steven Manchester [00:25:34]: Thanks, Chris. We appreciate you. Michael Ramos [00:25:35]: Yeah. Yeah. Absolutely, Chris. And thank you for being such an amazing host and making such a comfortable interview. Steven Manchester [00:25:39]: And thank you for everything you're doing for the dads out there, Chris. We appreciate that. We really do.

Discovering the Path to Better Father-Daughter Relationships In a recent episode of the "Dads with Daughters" podcast, host Dr. Christopher Lewis sat down with Madeline Anderson, author of Girl Dad: Stories, Lessons, and Advice from Girl Dads and Their Daughters. Madeline shared insights and stories from her book and personal life, shedding light on the unique and impactful father-daughter relationship. Below, we delve into the highlights of their conversation and explore how her insights can help fathers strengthen their bonds with their daughters. The Genesis of "Girl Dad" Madeline Anderson, inspired by the unique and nurturing relationship with her father, set out to write *Girl Dad*. She recognized that her bond with her dad was rare and wanted to share the principles that made their relationship special. The book is a culmination of her personal experiences and interviews with various fathers and daughters. The key lesson: making life fun and enjoyable for daughters from a young age can build strong, lasting relationships. Understanding the Importance of Small Moments A recurring theme in Madeline's book is the impact of small, consistent gestures over grandiose acts. During the podcast, she shared touching stories from daughters who cherished simple, heartfelt actions from their fathers. For instance, one father left a note in his daughter's freezer that she found after he moved her into college. Such acts of love and thoughtfulness resonate deeply, often becoming treasured memories. Building Lifelong Friendships Madeline emphasized the importance of fathers not only as authority figures but as friends. By making activities enjoyable and relating to their daughters' interests, fathers can cultivate friendship and trust. She shared an anecdote about her father building a playhouse in their attic, complete with a rock wall entry. This creative and fun project strengthened their bond, underpinning the larger message of her book—having fun together can transform the father-daughter relationship. Embracing Your Authentic Self Madeline also discussed the importance of fathers remaining true to themselves. Instead of sacrificing their interests, fathers should incorporate their daughters into their world. If a father enjoys hiking, for instance, taking his daughter along can create shared experiences and memories. When daughters feel included in their father's life, they are more likely to share their own worlds in return. The Power of Understanding Madeline urged fathers to prioritize understanding their daughters at an individual level. Simple practices like sharing "roses and thorns" of the day can open channels of communication and provide insights into their daughters' lives. By knowing her highs and lows, fathers can support their daughters more effectively and build deeper connections. Balancing Work and Family Madeline spoke about her father's ability to balance a demanding work schedule while maintaining a close relationship with his daughters. She admired his ability to integrate his work world with his family life, showcasing that with some creativity and effort, work commitments need not overshadow family time. This approach can provide daughters with positive role models and inspire them in their own professional pursuits. The Birth of Girl Dad Network Expanding on her book's mission, Madeline is launching the Girl Dad Network, an online community offering resources, mentorship, and a platform for fathers to connect and learn from one another. This network will feature monthly meetings, courses tailored by age group, gift guides, and resources for both fathers and daughters—intending to be a comprehensive support system for "girl dads" everywhere. The conversation between Dr. Christopher Lewis and Madeline Anderson illuminated the profound impact of conscious and loving fatherhood on daughters. Madeline's work serves as a reminder that it's the little things that often matter the most. By being genuine, involving daughters in their passions, understanding their needs, and balancing work and family life, fathers can build meaningful and lasting relationships with their daughters. For more resources, fathers can visit the Girl Dad Network at girldadnetwork.com or explore Madeline's book, *Girl Dad*, available through Amazon. As underscored by Dr. Lewis, dads don't need to be perfect; they just need to be present, engaged, and open to the journey of fatherhood. Remember, every small gesture counts, and every day is an opportunity to build a stronger bond with your daughter.   TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:16]: Welcome back to the Dads with Daughters podcast where we bring you guests to be active participants in your daughters' lives, raising them to be strong, independent women. Really excited to have you back again this week. Every week, I love being able to sit down and talk to you. I say this every week, but it's so true because I learn from you as much as I'm hoping that you're learning from the people that we have on, the resources that we're sharing to help you be that dad that you wanna be to your daughters. And every week, I love being able to bring you different people, different guests, different people with different experiences. Last week, you had an opportunity to meet Kekoa and Madeline Anderson. They both were on. I love having fathers and daughters on. Dr. Christopher Lewis [00:00:58]: And I introduced you to the fact that Madeline is the author of a book called Girl Dad, Stories, Lessons and Advice from Girl Dads and Their Daughters. And we didn't really talk a lot about that book. But let me give you a little more context. So Madeline is an author and entrepreneur. She's got a passion for neuroscience, psychology, writing, and speaking. She's the daughter of a girl dad. We met him last week. And he's a father of 3 daughters. Dr. Christopher Lewis [00:01:25]: So he's got a lot of experience in that. And over a number of years, she spent over a number of years, she had the opportunity to interview a wide array of fathers and daughters to write this book about how you can be the best dad that you can be to your daughters. It really fits in well with the podcast and what we do in fathering together. So I'm really excited to have her back again this week to talk more about this journey that she's been on to be able to help dance and to learn a little bit more about what she learned in that process as well. Madeleine, thanks so much for being back again this week. Madeline Anderson [00:02:02]: Thank you so much for having me, Christopher. I really appreciate it. Dr. Christopher Lewis [00:02:05]: Well, I am excited to have you back. And it was so fun having your dad on last week and learning about the journey that the both that both of you were on. And I love some of the stories that he was sharing and some of the stories you were sharing about golfing and being able to, be that multi sport, fed into this book. But I I guess I wanna go back to the genesis because you're not a mother. You're not a father. You're writing a book, though, about being a great dad to daughters, and I think that has to have come from what we heard last week in the relationship that you have with your own father. But give me some of the genesis of what made you decide that you wanted to spend the time, the effort to interview all these people, to gain all this insight, and then put this book out into the world. Madeline Anderson [00:02:54]: So I wrote this book because I have an incredible relationship with my dad. And, obviously, y'all heard that on the last podcast, but I had no idea how rare our relationship is. And I really want to change that. So that's the genesis of the book. And it started out with me writing stories with my dad and how he raised me and my 2 younger sisters. But then it turned into so much more than that as I started interviewing both dads and daughters from all over, like you mentioned. And I think it's really a culmination of their stories, lessons, and advice that really shine throughout the book. And the actual moment that I realized I wanted to write the book was actually an interesting one. Madeline Anderson [00:03:37]: I was driving in Santa Monica. I could tell you exactly what street I was on and where I was going, but I I just had a thought pop into my head that said, you should write a book called Girl Dad. And like I said, I had always known I had a great relationship with my dad, but this thought just kind of came out of left field. And I've recently read Rick Rubin's book, The Creative Act, A Way of Being. And there was something in it that really stood out to me as relevant to this conversation. And he talked a lot about artists being the vessels for bringing the art or the idea to life and how sometimes ideas just come to you. And you're meant to basically take that idea and put it out into the world. And I really feel that that was the case for girl dad. Madeline Anderson [00:04:18]: It felt like a calling that's bigger than me, bigger than my stories, and it was something that I almost had to do because it was so important. And I think that having that daughter perspective is hopefully really helpful for dads because I'm trying to shed light on what we care about, what we want from our dads, and how to have a great relationship with us. So that's kind of the the genesis of Girl Dad, and it's evolving every day. I'm so excited. I'm launching Girl Dad Network very, very soon here, and that'll be an online platform for dads with all kinds of different things, like community and monthly live meetings with me, resources for the dads, resource for the daughters. Just kind of a full, all encompassing girl dad takes me takes me and how many people this message reaches. Dr. Christopher Lewis [00:05:11]: You know, one of the things that you said in the past podcast was that and and you reflected that just a moment ago where you talked about how rare it was for you to realize the relationship between you and your dad was not the norm. And you realized that in college when you interacted with other women that didn't have that same relationship. Talk to me about that and what you were hearing from some of these other women about the relationships they did not have. And what were those women telling you about what they wished that relationship was and what was missing in that relationship? Madeline Anderson [00:05:49]: Yeah. It started the day that I moved in, and I lived in a dorm with I think it was there's 8 of us. So it was a 2 bedroom dorm with I know, I guess it was 6 of us. There was 2 bedrooms, 3 people in each bedroom, 1 bathroom, kind of a tough situation, but my dad helped me move in and he was there. He was so supportive. We grabbed dinner afterwards, the way he was helping me set up and everything. And then all 5 of the other girls were just there in awe. They didn't have a dad who was helping them move in. Madeline Anderson [00:06:19]: And I definitely took it for granted. It was like, you know, move in day course he's coming. That's what he does. Like, you know, he's just always there for me. And so it was, that was the first moment. And then after he left, they had told me a lot about that. Like, wow, I can't believe your dad did that. That was so nice of him. Madeline Anderson [00:06:34]: And I I really wish my dad would care for me like that. And and then obviously throughout college, I met ton of other girls who also had either no relationship with their dad or a very negative relationship. And they would say, you know, they hate their dad. You know, just really things that make my skin crawl a little bit and it and it hurts my heart, but it basically, it became very obvious to me that I had something very special And I always knew he was amazing, but I didn't realize how rare our relationship was. Dr. Christopher Lewis [00:07:01]: So you spent all this time, and you started kinda deconstructing the relationship that you had with your own father. And as you were looking at that, what were some of the big points, some of the things that really stood out to you that were unique in your relationship that you weren't seeing in some of the other relationships around you? Madeline Anderson [00:07:21]: I think it probably tends to start from a young age. And looking back to when me and my sisters were young, one thing he did consistently was make life fun. So he would just put himself in our shoes and try to make every situation fun for us. And by having fun with him, we became more than, you know, just a father daughter dynamic. We became friends. And so we've kind of built that friendship over the years. We're still great friends and he's also my dad and I'm also his daughter, you know, that you can be both. And I think that's one thing that really became clear throughout my adulthood and reflecting on these stories and talking with my younger sisters and trying to think back, okay, What was that thing dad did with us? You know? It's like the common theme is we had so much fun, and nothing was, like, too crazy or such a rare idea. Madeline Anderson [00:08:12]: It was all just, like, being silly or just hanging out with us and making us feel special. And one thing that comes to mind is he built us this playhouse, and it was just the coolest thing ever. He we had an attic, and so he transformed that attic into our playhouse. And he's super handy. So he did all the insulation and put in wood floors in the attic. And then what he did is he cut a hole in the top of our closet, and then he built a rock wall. And we were helping him throughout the process. So I have photos of me with little mask on up in the attic, and we went to REI and got the rock wall pieces and helped decide, okay, this one should go here. Madeline Anderson [00:08:48]: This is here. And then it became this epic playhouse where you had to crawl up a rock wall in the closet to get to this playhouse. And we called it Club Wahini because he was born in Hawaii and we would draw on the walls. And every time our friends would come over, they would sign the wall And we would be up there for hours and hours, like, every day, every weekend, we had sleepovers up there. And it was just such a fun thing that he did. And he just he thought of it because he's creative, and he's always thinking about, oh, how can we make this fun? He's he's just really good at turning any situation into something that you wanna be a part of. Dr. Christopher Lewis [00:09:24]: So beyond what you were learning specifically about the relationship between you and your dad because by taking a clinical approach to taking a look at the relationship, it's a it it kinda sets makes you have to step back and look from a macro view versus the micro view that you grew up in. But then you went beyond that, and you started to talk to other fathers, daughters about their relationships. What did you learn what did you start learning from those conversations that was eye opening for you as you were preparing and collecting all this data that would eventually be written in your book? Madeline Anderson [00:10:03]: The first thing that comes to mind is when I interviewed all the daughters, the same theme kind of kept coming up, which is it's all the little things that matter. Like, no daughter said, oh, you know, my dad is really special because on my birthday, he got me this, like, nice purse or, you know, something like big. It's all these little micro moments that add up over time. And funny enough, I had 2 daughters talk a long time, and it was like their favorite story about handwritten notes. One of them was a daughter who her dad helped her move into college as well. And their thing growing up was they would eat ice cream together on the couch. And so when he was moving in, he wrote on a little piece of paper, I wish I was eating. I was here eating ice cream with you and he put it in her freezer. Madeline Anderson [00:10:50]: And then that night when he left, she was feeling all sad and she went to go get some ice cream and she saw that note there. And she said she started crying, and it was so special. And she's moved multiple times since then. And she told me she's brought the note with her every time and puts it in her freezer. And it's so funny how it's just this simple note. That was only a few words. Right? But it meant the world to her. And then the second example was one of the daughters that I interviewed, she when she was going off to college, she was having a lot of anxiety. Madeline Anderson [00:11:19]: She has always kind of had a lot of anxiety, struggled with that. And she's grown up really close to home, doesn't like to leave home. And her college was in a different state. It was a flight away. And she was ultimately deciding that she didn't wanna go anymore because she couldn't handle it. And so her dad wrote her the kindest note just outlining how he's so proud of her, how she can do this, he'll be with her every step of the way, and just made her feel like she was capable. And so she ended up going to college at this school that was far away. She brought the note with her. Madeline Anderson [00:11:50]: She put it in her backpack. She said she took it to every single class, and she felt a sense of comfort just knowing that that note was in her backpack. It was almost as if her dad was there in her presence. And she also told me that she has that note still today even though she's past graduation and everything. And she said it's all kind of crumpled up and, like, it looks old, but she said she'll keep it forever. So I think those are two powerful stories that just go to show you that it's just these little micro moments that means so much to us daughters. And at the end of the day, we just wanna feel loved. We wanna feel seen and heard and special. Madeline Anderson [00:12:25]: And there's lots of ways to do that, but it could be as simple as a really genuine smile just like every day or a handwritten note or a big hug. Like, there's just these things that matter so much to us, and it's it's not rocket science necessarily, but it takes getting to understand us as individuals and what we need from our dads, to feel supported and loved. Dr. Christopher Lewis [00:12:49]: So you collect all this data. And as someone that went through a doctorate program and wrote a dissertation, I know what that's like, and especially qualitative data when you're pulling all kinds of stories together, and you're trying to figure out some type of semblance of order to all of this and putting it into thematic areas that make sense. Talk to me about some of the high level learning pieces that people are going to find as they go through this book and some of the main points that you are trying to put out there into the world. Not that you have to give away every secret because we want people to read the book, but what are some of the high level areas and things that you really are delving deeper into into in the book itself? Madeline Anderson [00:13:32]: Yeah. I think the first thing that I I would say is that it's a very positive book. I want dads to read this and to close it and be like, let's go. I'm so happy that I have a daughter. I'm so excited depending on what age level she's at. I'm so excited for her journey to raise her, but I really want people to have fun with it. And I think that plays into one of the first themes and takeaways, which is to don't stop being you. And I think it's an important one because I want you to be the happiest version of yourself because when you're happy, you're usually a better father, a better husband. Madeline Anderson [00:14:06]: It all starts with not taking away the things that you love. But this book, a lot of my, the, the stories and the themes throughout it talk about not giving those things up, but then in finding ways to include your daughter in them. And I think, you know, when you include her in your world, she will let you into hers. It might happen over time, especially as she gets older, but it pays dividends by making her feel like she's a part of your life and your passions. So I would say that's a that's a big one. Another takeaway would be getting to know your daughter and the importance of that and figuring out how to know your daughter. And there's some great tips in there like plain roses and thorns, which is basically asking her her rose of the day and her thorn of the day. So like a highlight of the day and something that maybe issue wish went differently and how powerful those conversations can be because she might be holding on to something and not going to speak up about it. Madeline Anderson [00:15:05]: But if you give her the floor and you say, what was your thorn of the day? Then maybe something will come up. Something's going on at school or she's having an argument with a friend and it's really weighing on her. And she might not say anything. But when you give her the microphone and you show her that you're there to support her, you might learn a lot. And same thing goes with the positive side too. You might learn some of her passions that you didn't recognize. So that's another big one. And then I talk a lot about work and life. Madeline Anderson [00:15:32]: And I think that's a big talking point for me, especially with my dad. He did such a good job of including me in his world with work. And so I never felt like my dad was spending too much time on work and not enough time with the family, even though he spends a ton of time on work. But I look at it as, wow. He's so amazing, so inspired by him. I hope to be as hardworking as him, and I don't look at as look at it as, you know, a negative or something that's taken away from me and my time. So I think there's a lot of tips on all three of those. There's plenty of, you know, tips on other things as well, but I would say those are some of the highlights. Dr. Christopher Lewis [00:16:09]: Now you talked about some of the things that you're planning to do. And as I'm sure going through college, moving into your career, this probably was not on your on your entrepreneurial journey of thinking that this was what you were going to hang your hat on and to put out into the world and to engage fathers in this way. So talk to me about where you are today, where you're going. You talked a little bit about that at the beginning, but let's talk about it again. I'd like to go a little deeper on that and what your hope is for what people are gonna take out of this book and to either take their own relationship to the next level or what that means, but share that with me as well. Madeline Anderson [00:16:49]: So got a lot of exciting things in the works. I think my biggest focus right now is Girl Dad Network, building that out. So there's going to be some programs which are like courses depending on age level of the daughters. There's going to be monthly calls with me where it'll be a live call with me and like anyone in the community who wants to join. And I think that will be a really powerful piece because we'll be able to dive into things that are going on in in the relationship and how to amend things or how to prepare for, you know, certain stages of life. And I'll go over different topics as well and really excited for that piece. And then you've got the community side, being able to communicate with other fathers who are in similar situations or have daughters of the same age. There'll be events live and virtual. Madeline Anderson [00:17:35]: Let's see. There's resources for the dads. I'm really excited about the gift guide actually because I'm building that with other daughters. So they can just go on there, add to cart, make it super easy for them. And it's all from the daughter's perspective once again. So they know, okay, if this is something that the daughters would want, then it's probably, very relevant. And then there's also resources for the daughter. So I'm building out, like, a mentorship program for the daughter, job board, and a college prep program as well. Madeline Anderson [00:18:03]: So just wanted to be a one stop shop for the dads, everything girl dad related. How can they have a great relationship with their daughter? How can they set their daughter up for success? It's an online community. So it's, yeah, that's my main focus right now. Super excited about that. And then I would say the second part of it is speaking. I'm doing a lot more speaking events and been really, really loving that. I think my main focus is just getting out in front of as many dads as possible, whether that be through the book, through the speaking, through the community, and just being able to make an impact on fathers and daughters and future generations. So that's my passion. Madeline Anderson [00:18:39]: And, yeah, I'm really looking forward to seeing where it takes me. Dr. Christopher Lewis [00:18:41]: So if people are interested in finding out more about the network, about the book, where should they go? Madeline Anderson [00:18:47]: Yeah. So for the network, girldadnetwork.com. And for the book, girl dad the book dot com. It's also on Amazon, but there's a link through the website as well if that's easier. Dr. Christopher Lewis [00:18:57]: And we'll put links in the notes today for all of you to be able to find this, to be able to go out, grab the book, and be able to learn from the book, from the father and daughter relationships that are in the book. You're definitely not going to wanna miss this, and you're going to want to learn from this journey that not only that Madeleine has been on with her own dad, but also the journeys of all these fathers and daughters because it's really important to be able to take in all of this, like we talk about every week on the show, and be able to be open to learning, to be open to the journey, and know that you don't have to be a perfect dad. But there are things that you can do to be able to set up some building blocks that will help you to be the dad that you want to be. So I just want to say thank you, Madeleine, for making this a passion area for yourself, for working with fathers in so many different ways, for putting this out into the world. And I wish you all the best. Madeline Anderson [00:19:48]: Thank you, Christopher. It's an honor to be here, and I appreciate everything that you're doing for all the dads out there as well. Dr. Christopher Lewis [00:19:54]: If you've enjoyed today's episode of the dads with daughters podcast, we invite you to check out the fatherhood insider. The fatherhood insider is the resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step roadmaps and more, you will engage and learn with experts, but more importantly dads like you. So check it out atfatheringtogether.org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with daughters is a program of fathering together. We look forward to having you back for another great guest next week, all geared to helping you raise strong empowered daughters and be the best dad that you can be. We're all in the same boat, And it's full of tiny screaming passengers. We spend the time. We give the lessons. We make the meals. We buy them presents and bring your a game. Because those kids are growing fast. The time goes by just like a dynamite blast. Calling astronauts and firemen, carpenters, and musclemen. Get out and be the world to them. Be the best that you can be.

Dr. Lillian Siu and Dr. Melvin Chua discuss the new technologies and novel therapeutics that were featured at the 2024 ASCO Breakthrough meeting. TRANSCRIPT Dr. Lillian Siu: Hello and welcome to the ASCO Daily News Podcast. I'm Dr. Lillian Siu, a medical oncologist and director of the Phase 1 Trials Program at the Princess Margaret Cancer Center in Toronto, Canada, and a professor of medicine at the University of Toronto. On today's episode, we'll be discussing key takeaways from the 2024 ASCO Breakthrough meeting in Yokohama, Japan. Joining me for this discussion is Dr. Melvin Chua, who served as the chair of Breakthrough's Program Committee. Dr. Chua is the head of the Department for Head, Neck and Thoracic Cancers in the Division of Radiation Oncology at the National Cancer Center in Singapore. Our full disclosures are available in the transcript of this episode. Dr. Chua, it's great to be speaking with you today and congratulations on a very successful Breakthrough meeting. Dr. Melvin Chua: Thanks Dr. Siu. It was really inspiring to come together again to showcase the innovative work of world-renowned experts, clinicians, researchers, med-tech pioneers, and drug developers from around the globe. Our theme this year was inclusivity and thus it was important to bring people together again in the Asia Pacific region and to foster international collaborations that are so important in advancing cancer care. This year, we invited 65 international faculty, of which 55% were from Asia. Also, importantly, we achieved approximately a 50-50 split for male to female representation. These are remarkable statistics for the meeting, and we really hope to retain this for future Breakthrough [meetings]. Dr. Lillian Siu: The meeting featured renowned keynote speakers who shared great insights on new technologies and therapies that are shaping the future of drug development and care delivery. Let's first talk about artificial intelligence and the keynote address by Dr. Andrew Trister. He gave a very interesting talk titled, “Plaiting the Golden Braid: How Artificial Intelligence Informs the Learning Health System.” What are the key messages from his talk? Dr. Melvin Chua: Couldn't agree with you more, Dr. Siu. Dr. Trister is the chief medical and scientific officer of Verily, a precision health company. He previously worked in digital health and AI at The Bill and Melinda Gates Foundation, and worked at Apple where he led clinical research and machine learning with Apple partners. But perhaps it was really his background and training as a radiation oncologist that was most pertinent as he was able to weave both the components of new AI models and the applications and pitfalls in the clinic to the audience. Dr. Trister provided a very high-level view through the history of AI and showcased the progression of the different AI models and he basically explained between deep and shallow methods as well as deductive logic versus inductive probabilistic methods. He then provided several clinical examples where these models have shown their utility in the clinic, for example, pathology and so forth. At the same time, he illustrated several pitfalls with these models. So overall, I think Dr. Trister's talk was very well received by the audience with several key messages, including the importance of [using] high-quality data as the basis of a good AI model. AI was also addressed in an Education Session that looked at Artificial Intelligence in the Cancer Clinic. And we had a panel of experts that highlighted current progress and successes with AI in the clinic, advances with AI assisted pathology for clinical research and precision medicine, large language models (LLMs) for applications in the clinic, and how we could leverage AI in precision oncology. And from this session, I had several key takeaways. Dr. Alexander Pearson [of the University of Chicago] gave a very illustrative talk on how multimodal information across clinical omics, radiological information and multi omics could be used to improve diagnostic tasks and clinical prediction across different cancers. And Dr. Joe Yeong [of Singapore General Hospital] gave a very good talk on how AI can be applied in digital pathology to accelerate research in immunology and help in the development of immunotherapies. Dr. Danielle Bitterman [of Brigham and Women's Hospital] shared very good examples of how LLMs could be used in a clinic. And I think the example that really stood out for me was how LLMs could be deployed to create responses to patient queries. And of course, the big question in the room was: How could AI eventually encapsulate compassion in their response? I think this again showcased how LLMs could really help to accelerate our clinical work going forward. And ultimately circling back to data, Dr. Caroline Chung [of MD Anderson] gave a very poignant description on the importance of data quality and how poor-quality data could eventually lead to underperforming AI models. So all in all, I think this was a great session. And what do you think, Dr. Siu? Dr. Lillian Siu: Melvin, I totally agree with you. I like all your comments and I really enjoyed the keynote as well as the session on AI in the cancer clinic chaired by Dr. Pearson. I think all these sessions were really informative. Discussions on the latest AI and machine learning, algorithms and technologies on digital pathology, LLMs and big data, as you said, really enables the attendees, especially clinicians like me, to gain a deep understanding of how AI can be translated to practical applications. Dr. Melvin Chua: Great. So, Dr. Siu, let's talk about some of the novel therapeutics that were featured at the meeting. Again, this was an important session for Breakthrough, and it's always been there. So could you share some highlights from the sessions on novel drug development from your perspective? Dr. Lillian Siu: Yes, indeed. Drug development is such an exciting aspect of this meeting. On Day 3 of the meeting, we had a keynote by Dr. Shimon Sakaguchi of Osaka University, who discussed “Targeting Regulatory T cells (Tregs) in Cancer: The Science, Trials, and Future.” And he talked about T cells, especially Treg biology, the role of Tregs in immune regulation, new developments in Treg immuno-oncology drugs, and how we can actually target Tregs to treat early cancers, etc. This talk is particularly exciting because there are now anti CCR8 antibodies in the clinic that specifically target Tregs, and some early signals of anti-tumor activities are already being observed. Dr. Sakaguchi also emphasized the importance of combination sequence and timing of drugs for the successful use of cancer immunotherapeutic agents. I also want to emphasize the Education Session that followed, titled, “The Future of Immunotherapy, New Drugs and New Ideas.” In that particular session, we heard about engineering T-cell immunity to eradicate tumors. We heard about CAR T-cell therapy in GI cancers, novel immunotherapeutic combinations, and T-cell engagers, which are bispecifics in cancer. While success with some of these immunotherapeutic modalities, such as cell therapies and T-cell engagers have been largely seen in hematological malignancies, we are beginning to observe efficacy signals in solid tumors. For example, the CAR T targeting Claudin18.2 in gastrointestinal cancers and the recently approved FDA-approved DLL3/CD3 bispecific T-cell engager, tarlatamab, in small cell lung cancer are really exciting examples. We also heard from investigators who are exploring neoadjuvant therapies in the neoadjuvant therapy session, and the key takeaway from that session is that we have growing interest in using neoadjuvant therapy or perioperative therapy. In other words, neoadjuvant plus adjuvant therapy in different cancers. In the neoadjuvant session, there were updates provided by different experts on the roles of neoadjuvant therapy in melanoma, liver cancer, bladder cancer, and nasopharyngeal cancer. Increasingly, there is randomized trial evidence to support the use of neoadjuvant therapy or perioperative immunotherapy in several cancer types with survival-based endpoints. Very exciting indeed. Dr. Melvin Chua: Indeed, I couldn't agree with you more. I think one of the things that went into designing the case-based discussions this year was that we wanted to talk about cancers that were relevant to this part of the world and hence we again showcased lung cancers, gastric cancers and melanomas, and whereby we have again perspectives from an expert from the West coupled to an expert from the East, thereby showcasing the diversity of practice around the world. The other thing that we did this year was we decided to pair the case-based discussions with the keynotes and the Education Sessions as well. For example, on Day 3, we had Dr. Sakaguchi speak on Tregs, as you mentioned. And this was followed by an in-depth session on new immunotherapies, and then followed by a case-based discussion on different melanoma cases on the role of neoadjuvant immunotherapy in this disease, and the strikingly relevance of response to prognostication. This is an important trait that we're seeing now that seems to pan out across different cancers, where we find that neoadjuvant response to combination systemic therapies and/or radiotherapy is a strong prognosticator. Dr. Lillian Siu: So, Dr. Chua, we've discussed some breakthrough treatments and promising advances in cancer care, and we've touched upon some barriers to success in cancer treatment. I would like to ask you about the keynote address by Dr. Raffaella Casolino of the World Health Organization, who spoke passionately about efforts by the WHO and its partners to build equity in cancer care. Can you share some highlights with us? Dr. Melvin Chua: Absolutely, Dr. Siu. In spite of the tremendous advances we've seen in recent years in oncology, there are still major disparities in cancer care, such as cost and access, which affect patients worldwide. I think Dr. Casolino's talk was a very nice overview whereby she showed, first of all, the WHO's impact in terms of the WHO Cancer Resolution initiative that was implemented in 2017, where through this initiative, WHO has impacted 100 countries, invested $1 billion in funds, and that has led to millions of lives saved. But she then really drilled down to some of the key examples of the focus of the WHO in terms of equalizing care in cancer. I think one which struck me was the appreciation of the disparities in the clinical trials landscape. I think it is clear that there's still a huge barrier to clinical trials between the high- and middle-income countries and the low- and middle-income countries, and the majority of clinical trials these days are industry sponsored and we really need to look at leveling the playing field in this regard. Then she highlighted the WHO's work on trying to lower the barriers to precision oncology. And I think there are several issues in that sense, but I think what the WHO has really worked hard on is promoting education for genomic medicine, where they've done several reviews with experts around the world to educate the field across the world on how we interpret and apply genomics in the clinic. So all in all, it was very interesting to hear Dr. Casolino's insights from a policy perspective, and again, this emphasizes that there's so much work to be done at the end of the day and the dialogue needs to continue. We also heard about policy, academic and industry perspectives in the context of clinical trials, and that led to a discussion on real-world evidence generation for regulatory approvals. It was very nice that we had a session on that at the end of Breakthrough 2024 (Real-World Evidence and Clinical Trials: Beyond the Ivory Tower). And in that session, we heard from Dr. Shaalan Beg [of the NIH], and Dr. Janet Dancey [of Queen's University] who represented views from academia and Dr. Hidetoshi Hayashi [of Kindai University Hospital] shared perspectives on decentralized trials. I'd like to encourage our listeners to watch these sessions if they were unable to attend. The content is very rich, and I'm sure they'll learn from it. Dr. Lillian Siu: Thank you so much, Dr. Chua. Is there anything else you would like to cover before we wrap up the podcast today? Dr. Melvin Chua: Thank you, Dr. Siu. The thing I really want to emphasize is, apart from all these Educational Sessions and having very eminent keynote speakers, one of the key points that we really want to bring out for Breakthrough is to showcase the high-quality research. This year we had 300 abstracts submitted and they were all high quality, cutting across trials, omics research, AI and technology, and eventually we selected 235 of them and we were able to showcase some of them across three oral sessions over three days. I think this is an important component of Breakthrough that we really wish to continue building upon where people are now excited to use this forum to present their work. Dr. Lillian Siu: Thank you so much, Dr. Chua. I really enjoyed our discussions today. I look forward to seeing how the Breakthrough meeting will continue to grow in future years. Dr. Melvin Chua: Thank you again, Dr. Siu. Thank you for all your leadership and efforts in making Breakthrough a successful meeting series the past few years. Dr. Lillian Siu: Thank you to our listeners for your time today. You'll find links to the session 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 podcast. 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. Find out more about today's speakers:   Dr. Lilian Siu  @lillian_siu  Dr. Melvin Chua  @DrMLChua    Follow ASCO on social media:    @ASCO on Twitter    ASCO on Facebook    ASCO on LinkedIn      Disclosures:   Dr. Lillian Siu:  Leadership (Immediate family member): Treadwell Therapeutics  Stock and Other Ownership Interests (Immediate family member): Agios    Consulting or Advisory Role: Merck, AstraZeneca/MedImmune, Roche, Voronoi Inc., Oncorus, GSK, Seattle Genetics, Arvinas, Navire, Janpix, Relay Therapeutics, Daiichi Sankyo/UCB Japan, Janssen, Research Funding (Institution): Bristol-Myers Squibb, Genentech/Roche, GlaxoSmithKline, Merck, Novartis, Pfizer, AstraZeneca, Boehringer Ingelheim, Bayer, Amgen, Astellas Pharma, Shattuck Labs, Symphogen, Avid, Mirati Therapeutics, Karyopharm Therapeutics, Amgen   Dr. Melvin Chua:  Leadership, Stock and Other Ownership Interests: Digital Life Line  Honoraria: Janssen Oncology, Varian  Consulting or Advisory Role: Janssen Oncology, Merck Sharp & Dohme, ImmunoSCAPE, Telix Pharmaceuticals, IQVIA, BeiGene  Speakers' Bureau: AstraZeneca, Bayer, Pfizer, Janssen   Research Funding: PVmed, Decipher Biosciences, EVYD Technology, MVision, BeiGene, EVYD Technology, MVision, BeiGene  Patents, Royalties, Other Intellectual Property: High Sensitivity Lateral Flow Immunoassay for Detection of Analyte in Samples (10202107837T), Singapore. (Danny Jian Hang Tng, Chua Lee Kiang Melvin, Zhang Yong, Jenny Low, Ooi Eng Eong, Soo Khee Chee)    

JCO PO author Dr. Jonathan D. Tward, M.D., Ph.D., FASTRO, at the HCI Genitourinary Cancers Center and the Huntsman Cancer Institute at the University of Utah, shares insights into his JCO PO article, “Using the Cell-Cycle Risk Score to Predict the Benefit of Androgen-Deprivation Therapy Added to Radiation Therapy in Patients With Newly Diagnosed Prostate Cancer.” Host Dr. Rafeh Naqash and Dr. Tward discuss how the cell-cycle risk score predicts the benefit of androgen-deprivation therapy in prostate cancer treatment. TRANSCRIPT Dr. Abdul 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, Assistant Professor at the OU Health Stephenson Cancer center. Today, we are excited to be joined by Dr. Jonathan Tward, Leader at the HCI Genitourinary Cancer Center, and Vincent P. and Janet Mancini Presidential Endowed Chair in Genitourinary malignancies at the Huntsman Cancer Institute at the University of Utah. Dr. Tward is also the lead author of the JCO Precision Oncology article titled “Using the Cell-Cycle Risk Score to Predict the Benefit of Androgen-Deprivation Therapy Added to Radiation Therapy in Patients With Newly Diagnosed Prostate Cancer.”  At the time of this recording, our guest's disclosures will be linked in the transcript.  Doctor Tward, welcome to the podcast and thank you for joining us today. Dr. Jonathan Tward: Thank you so much, Dr. Naqash. I'm excited to share this important research with your audience.  Dr. Abdul Rafeh Naqash: Awesome. For the sake of simplicity, we'll refer to each other using our first names, if that's okay with you.  Dr. Jonathan Tward: That's great.  Dr. Abdul Rafeh Naqash: Okay. So, Jonathan, this complex but very interesting topic revolves around a lot of different subtopics as I understand it. There is genomics, there are implications for treatment, there is machine learning and computational data science research. So, to start off why you started this project or why you did this research, could you, for the sake of our audience, try to help us understand what androgen deprivation therapy is? When is it used in prostate cancer? When is it used in combination with radiation therapy? And that would probably give us a decent background of why you were trying to do what you actually did in this research. Dr. Jonathan Tward: Yes, thank you very much. So, men who are diagnosed with localized prostate cancer, which is the majority of prostate cancer diagnosis, are faced with a lot of treatment decisions. And those decisions range all the way from, “Should I just go on active surveillance with the idea that it might be safe to treat later?” to “Should I consider surgery or radiation?” And then there's various forms of radiation. Now, as a radiation oncologist, one of the things that I have to consider when I meet a patient with localized prostate cancer who is pondering receiving radiation therapy, is whether or not we want to intensify treatment by doing more than just radiation alone. And androgen deprivation therapy, very specifically also thought of as chemical castration, what that really is is some kind of therapy where you are trying to reduce a man's testosterone levels to nearly zero. And the rationale for using androgen deprivation therapy in prostate cancer and in this case, specifically localized prostate cancer, is that one can think of testosterone almost as the food and growth signal for prostate cancer. There have been numerous prospective randomized trials that have been performed in the past that have clearly demonstrated that adding androgen deprivation therapy to certain contexts of patients with localized prostate cancer receiving radiation improves the outcome, including risk of metastasis and overall survival.  The problem is, we don't want to just intensify therapy for everybody who walks through our doors with localized prostate cancer. Some men have lower risk disease, and some men have higher risk disease. And conventionally, the way we make this decision is by looking at things like NCCN risk groups, which kind of lump patients into a few different boxes, generally speaking, called low risk, intermediate risk, and high risk. And if you think of those risk groups, the patients with the contemporary standard of who to add ADT to are men who are considered high risk localized, or men who are considered unfavorable intermediate risk localized. That being said, I think there's a recognition that we're overtreating some unfavorable intermediate risk men and undertreating them, and the same could be said of high-risk disease. So, I think we're always looking for better tools that make it a little bit more personalized, rather than lumping men into just one of several boxes. Dr. Abdul Rafeh Naqash: Sure. And this sort of reminds me of the oncotype DX, in a way, trying to connect people with ER/PR, breast cancer, and where chemotherapy, plus anti-estrogen and progesterone therapy may be applicable. So, I think you were trying to do something similar in this research, and as far as I remember, please correct me if I'm wrong, this is knowledge that I remember from my board exams, we classify this high risk, intermediate risk, and low risk based on the Gleason score. Is that correct? Is that still true, or has this changed? Dr. Jonathan Tward: It's still true. Conventional risk stratification, which is still used, literally only looks at a few parameters. You mentioned one, which is the Gleason score, which is really a human subjective judgment by a pathologist about how deranged cells look under a microscope. That's one parameter. The second parameter is the PSA value at the time of diagnosis. And the third parameter is the cT stage, which is really based on the digital rectal exam. Now, when you ponder that the entirety of our risk classification system is based on two subjective and one objective pieces of information, meaning what a Gleason score looks like, what the T stage is based on human interpretation, and then the only objective piece of data, PSA, it's rather rudimentary way of classifying men. I mean, it's done us well since the late ‘90s, when that particular classification system was derived. But it strikes me as odd that we should take all newly diagnosed localized prostate cancer patients and say you fit into one of three boxes, when we know there's so much more complexity to people and so many different treatment options and choices out there, which we're trying to match to the patient to ensure that we right size the treatment for them. Dr. Abdul Rafeh Naqash: Understood. Now, as we go into the precision medicine component of this research, there's genomics research in metastatic cancers. But is there any genomics research in early-stage prostate cancer where there have been differences that have been identified between the intermediate low risk, high risk? Is that something that has been explored to date? Dr. Jonathan Tward: Well, there are certainly somatic mutations that track with certain aggressive features. But I think when I think about the spirit of your question, within the localized prostate cancer space, there's been several molecular signatures that have been developed and, in fact, been commercialized that have been shown quite clearly that if you have a certain array of gene expressions, let's say, that that can correlate with metastasis or risk of recurrence or death. And the work that we're talking about today is one that actually uses one of the commercially available biomarkers, commercially it's known as Prolaris. But very specifically, in the work that I think we're discussing today, what we're looking at is cell cycle progression genes. And these are genes that maybe, to simplify it, are sort of hallmarks of how quickly cells are turning over. And what's interesting about looking at cell cycle progression is it's not certainly particular to prostate cancer. I mean, you could make an argument that cell cycle progression genes are probably relevant measures in any cancers, but there's been much work done over the past 15 to 20 years that have clearly validated that this particular cell cycle progression gene signature, which is now commercially available, clearly correlates with risk of progression, risk of metastasis in localized prostate cancer patients, whether they're receiving surgery or radiation. But what we've done is we've built upon this molecular work and added clinical risk features and added results of prospective randomized trials to use this test to personalize the precise risk reduction of what would happen to a man who is pondering adding ADT to radiation therapy. So, it's a very powerful precision tool.  Dr. Abdul Rafeh Naqash: Sounds very interesting. When you go deeper into this platform, is this genomic testing platform, does it incorporate RNA transcriptome or is it DNA, or is it a composite of both? Dr. Jonathan Tward: There are various molecular tests that are out there. In this particular case, these are mRNA expression levels of cell cycle progression genes, and they are kind of calibrated against some normal housekeeping genes, which is how the test is run. Dr. Abdul Rafeh Naqash: Understood. So, from what I understand in the discussion, you very appropriately said, in fact in your first paragraph, the goal here is to match patient level precision medicine approaches and reconcile them with population level therapeutic options. It's a very catchy statement. Can you help explain for our audience how you tried to do that? And this goes back to the question that you were trying to understand, where to use combination therapy in a localized prostate cancer based on risk stratification and deriving that risk stratification from the cell cycle score and then arriving to certain thresholds. So could you go through that in simple terms to help us understand how you tried to do it and what was the outcome and what are the implications of that? Dr. Jonathan Tward: Sure, there's a lot to unpack there, but I'll do my best to simplify it. So, we'll start with the basic question that faces a patient and their radiation oncologist, which is, if they're going to receive radiation, should you add hormone therapy? And if hormone therapy was completely nontoxic, you'd say, “Sure, just add it to everybody if there's a benefit.” But the problem is, of course, hormone therapy is associated with all kinds of unpleasant side effects and additional risks, so we don't want to utilize it unless we're sure that the benefit is clear. When you think about the way most of oncology decides whether or not adding an intervention should be done in a particular patient context, it's actually been derived originally from prospectively randomized trials, which usually assigned a hazard ratio or some kind of known relative reduction to doing ‘thing B' versus ‘thing A' or ‘thing B' in addition to ‘thing A'. But what's curious about always looking at hazard ratios and saying that those are the reasons why you should do additional things, discounts a really important fact, which is the baseline risk of something bad happening has to be accounted for first before you decide whether or not it a relative risk reduction matters. So to state more clearly, if I knew a prostate cancer patient sitting in front of me only had a 2% risk of developing metastasis within 10 years, if I just did radiation alone, if I then say adding hormone therapy might cut that in half from 2% to 1%, a patient might say, “You know what? I'm not sure I want to accept the toxicity of many months of hormone therapy to cut my risk of metastasis from 2% to 1%.” But if you had a patient where that risk was 20% risk of metastasis with radiation alone, and you told them I can cut that risk down to 10% or 12%, then that's something they would seriously consider.   And so what this work really does is precisely that. It gives us a tool where, using the molecular signature of the cell cycle progression genes, which afford a patient a certain risk of metastasis, and also taking into account clinical risk factors that we know are prognostic, Gleason score, PSA, their age, how many cores of the biopsy were possible. We use all this information, and I'll use a strange term, multiplex it into a robust risk model that will prognosticate extremely clearly what that patient's precise risk of metastasis will be within the next 10 years, and this is the key point, if they receive radiation alone.   So, think of this work in two phases. Phase one is calibrate the risk in a patient if they get radiation alone, by using both molecular and clinical prognosticators. But then take the power of numerous randomized trials, which have clearly set the hazard ratio reduction for adding the hormone therapy, and then using mathematical principles, applying that hazard ratio risk reduction to the absolute risk. And then what you ultimately do is, at a very individual level, have a patient sitting in front of you where you can say, “Mr. Jones, I've run this test on you, and I can tell you definitively that if you receive radiation therapy for your localized prostate cancer, the risk of metastasis will be 12%. But if you add, let's say, six months of hormone therapy, that could be reduced to 7%, and the absolute risk reduction might only be 5%.” And if you think about that number in a number needed to treat mentality, then you could say, “Listen, I have to give 20 men identical to you, hormone therapy for one to benefit. Is that worth it to you?”   And what it really does is it empowers the patient. Rather than following a guideline that says, “Effectively, thou shalt do this for this risk group,” you really want to engage the patient in the conversation about the risk benefit of what you're going to do. And I think it's uncommon in oncology for physicians to be able to very precisely tell a patient sitting in front of them, if you do ‘thing A', this is the risk, something bad happen. If you do ‘thing B', this is how the risk reduces. And I think now we really get into shared decision making, rather than a, “Trust me, I'm a doctor,” paternalistic situation. Dr. Abdul Rafeh Naqash: That's a very interesting approach. Again, you're basically personalizing the personalized medicine approach, refining it further, and involving the patient in discussions, which helps them understand why something would make sense. And some of this, as you might already know, people have tried to do in some other tumor types, hasn't necessarily led to significant clinical decision-making changes. But I think the way the field is evolving, especially this research that you published on and others are working towards, will hopefully result in more personalized approaches for individual decision making for these patients.   Now, I do understand that simplicity sometimes results in more uptake of some information versus when sometimes things get more complex. So, in your assessment, when you came up with these results, you looked at the genomic score, you took the randomized clinical trial data, you did the absolute risk reduction. From what I understood in the manuscript, it does look like you did come up with a threshold of what would appropriately risk stratify individuals, meaning individuals that are at a higher risk if they cross that threshold, versus individuals that are at a lower risk if they cross that threshold. Is that a fair statement or is this a continuum? So there is no binary, but this is over a scale that this assessment can be made. Dr. Jonathan Tward: So, there are elements of your summary that are fair, but this is a continuum which allows any individual to accept whatever risk reduction they want. That being said, there is no standard in oncology for what percent risk should you intensify a treatment for? And when you poll physicians and doctors as to how much reduction in death or how much reduction in metastasis, doctors and patients are all over the map at what they consider to be a threshold. But we designed these thresholds actually from prior work, based on surveying both patients themselves, as well as experts who were on cooperative trial group steering committees, and ask them, essentially, “At what level of risk reduction would you want to intensify treatment?” And what's interesting is most people who are asked that question are willing to do more treatment intensity for an important outcome like metastasis if the absolute risk reduction of that event happening is 5%. So as a general principle, that's how it was set.  These thresholds in the current paper we're discussing actually weren't defined in this current work. They were defined in prior works, where we had clearly shown in retrospective data sets that they could discriminate very well who does or doesn't benefit from hormone therapy. What's, I think, novel about this paper, even though we had previously validated those thresholds, is that now that we're using the randomized trial data, it's extremely robust in our risk estimates, and we can say that it's truly a predictive biomarker. Because it's one thing to prognosticate an outcome, but predict a difference in treatment A versus treatment B usually requires randomized trial data so that you get the highest level of evidence and the confidence that it works. Dr. Abdul Rafeh Naqash: So the next steps for this very, very provocative research, is it something prospective validation or are you going to try to utilize maybe proper group trial data or other pharma trial data, individual patient data to risk stratify these individuals and validate?  Dr. Jonathan Tward: So these thresholds, for example, that you refer to are very well validated. There's multiple prior studies, well over at this point, 1500 patients where there's validation. And yes, we have reached out to cooperative groups to do some additional validation. That being said, this work is already ready for prime time and being used. In fact, this test is the commercially available Prolaris test. The results gleaned from this work are published on the score report that a patient and a physician receives. So the reality is that this is already existing as a clinical tool in the community. And the NCCN guidelines also support the use of this and other tests to move from a stratification to personalized medicine. So it's not like this is so much in the experimental realm as it is effectively a complete tool that is being used today. And effectively, it's available for any patient or physician diagnosed with localized prostate cancer to immediately order on biopsy tissue. Dr. Abdul Rafeh Naqash: One naive question, Jonathan, I wanted to ask is most prostate cancers tend to be prostatic adenocarcinoma. So if it's a neuroendocrine localized prostate cancer, does the same risk assessment apply? Because neuroendocrine tumors in general seem to be higher replication stress or higher tendency to metastasis. Does it change from your perspective, from the genomic assessment standpoint, the CCR score standpoint? Dr. Jonathan Tward: That's a very interesting question, because what I will tell you is that there are probably a lot of, well, I wouldn't say a lot, but there are some neuroendocrine cancers mixed in with the adenocarcinomas that no one identified as neuroendocrine, which in a way were baked into the cake of the risk signature. Even though that is so, I dont think we've independently looked very specifically at known neuroendocrine cancers and compared them to the adenocarcinomas. What I would actually argue though, is that if you have a neuroendocrine cancer sitting in front of you, the point about whether or not you're adding ADT is relatively moot because neuroendocrine cancers may or may not respond to ADT, and you have to start considering chemotherapeutic-like decisions.   So the question, which is very interesting and academic, is that I would presume the cell cycle progression score should be elevated, although I don't know that in a neuroendocrine cancer, this tool doesn't appear to be useful at this moment for neuroendocrine cancers because we're not making decisions about chemo. That's an interesting and provocative question, and now you make me want to study that. So potentially, the next paper would be neuroendocrine cancers, whether or not it might prognosticate using a topicide or something else like this. But we would have to rely on prospective trial data as well to see whether or not we could use it the same way.  Dr. Abdul Rafeh Naqash: Hopefully, if you do work on it, then you can submit the manuscript again to JCO PO for us to talk again. Dr. Jonathan Tward: Yeah, and you'll be on the author bar.  Dr. Abdul Rafeh Naqash: Appreciate the inclusion. So thank you so much, Jonathan, for talking to us about the science. And a few quick minutes about yourself. Can you tell us a little bit about your career trajectory, how you ended up doing what you're doing, and maybe some lessons learned and some advice for early career junior investigators that would be helpful for them?  Dr. Jonathan Tward: Yes, that's a happy memory. When I was a young undergrad, I was fortunate to do some volunteer work in a radiation oncology department and had mentors there who guided me into considering a career in medicine and specifically a career as a physician scientist. So I'll start with the best advice is to get mentors early on and throughout your career who are really interested in your career development and who are accomplished that can kind of help you along. But I went to medical school with an open mind and continued to love oncology. I think it has some of the most complex questions that are unanswered. It is very high stakes oncology. There's still a lot of death and disability and consequences of our therapies. And I just love the idea of working in an environment, both clinically and as a researcher, to try to solve some of those questions like, how do I improve outcomes? How do I make therapy less toxic?  And radiation oncology for me, was a nice fit in genitourinary cancer, I guess, specifically because mid GU cancer realm patients are presented with a menu of treatment options. It's kind of interesting. It's a little bit unlike other cancers. But I had fantastic mentors throughout both my medical school as well as residency program who really helped guide me and encourage me along the way. And so without spending too much time, I would say go out of your way to find people who are successful at what they do, are interested in making you better, and really sit at their knee and listen to them when they are trying to guide you because they really have your best interests in mind. And I think as a mentor and a mentee, what makes me most proud is watching people I've trained go out and succeed. I mean, the reward of being a mentor is watching your mentees succeed.  Dr. Abdul Rafeh Naqash: Thank you. Appreciate all those words of wisdom, Jonathan, and excited to see all the subsequent steps and results from the research that you're doing. Thank you again for joining us today and providing a very simple summary of a very complex topic which I think our audience and perhaps some of the trainees listening to this podcast will appreciate. We really appreciate your time.  Dr. Jonathan Tward: Thank you so much, Rafeh.  Dr. Abdul Rafeh Naqash: And 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.     Dr. Tward Diclosures:   HonorariaCompany name: Bayer Consulting or Advisory RoleCompany name: Myriad Genetics, Blue Earth Diagnostics, Janssen Scientific Affairs, Merck, Bayer, Boston Scientific, Myovant Sciences, Myriad Genetics, Lantheus Medical Imaging Research FundingCompany name: Bayer, Myriad Genetics Travel, Accommodations, ExpensesCompany name: Myriad Genetics, Bayer

Fatherhood is a multifaceted journey laden with challenges, joys, fears, and triumphs. On the latest episode of the Dads with Daughters podcast, we welcome a special duo—Kekoa Anderson and his daughter, Madeline Anderson author of Girl Dad: Stories, Lessons, and Advice from Girl Dads & Their Daughters. Their insightful conversation unveils the essence of father-daughter relationships, the intricacies of raising daughters, and the profound impact of intentional parenting. The Initial Excitement and Overwhelming Responsibility When asked about the first moment he realized he was going to be a father to a daughter, Kekoa Anderson recalled it as an overwhelmingly positive time. He highlighted the sudden surge of responsibility that came with the birth of his daughter. This initial moment of excitement quickly paved the way for a lifelong journey of learning and adaptation. Kekoa described fatherhood as a process of evolving fears and challenges. From protecting an innocent little girl to dealing with the complexities of adolescence, each stage brought new hurdles. However, the underlying theme remained the same: the importance of being present and proactive in his daughters' lives. Developing Unique Relationships One of the key points discussed in the podcast was the necessity of building unique relationships with each child. Kekoa emphasized the importance of recognizing each daughter's individuality. He talked about creating bonds through shared interests like work and golf, which allowed him to engage with each daughter uniquely. Madeline fondly recounted her memories of being included in her father's work and the significant role golf played in their relationship. Guiding Through Challenges and Building Confidence Madeline also shared an insightful story that illustrated how her father's confidence in her abilities played a crucial role in shaping her self-esteem. At just 16, Kekoa entrusted her with attending a pre-proposal meeting, a task that seemed daunting at first but ultimately empowering. This experience, among many others, instilled in Madeline a sense of confidence and independence that she carries with her into adulthood. Kekoa explained his approach to parenting as one that focuses on guiding his daughters to the answers rather than giving them directly. This method built their confidence and equipped them with problem-solving skills essential for their future endeavors. Cherishing the Journey One of the most compelling parts of the conversation was the mutual respect and admiration between Kekoa and Madeline. Madeline expressed her awe at her father's thoughtful and supportive nature. She highlighted how the realization of her unique father-daughter relationship dawned on her during college when she noticed the absence of such bonds in her peers' lives. Kekoa, in turn, shared how reading Madeline's book “Girl Dad: Stories, Lessons, and Advice from Girl Dads and Their Daughters” was a reflective experience for him, reminding him of the many special moments they shared and the lessons they both learned. Advice for Fathers The episode concluded with the "Fatherhood 5," where both guests shared their insights and advice. Madeline stressed the importance of showing up and understanding your daughter. Knowing her passions, love language, and personality can significantly enhance the father-daughter relationship. Kekoa added the wisdom of enjoying the journey and not rushing through the moments. He likened it to the gentle pace necessary in a game of golf, emphasizing the importance of taking your time and appreciating each step of the way. The conversation with Kekoa and Madeline Anderson on the “Dads with Daughters” podcast encapsulates the essence of fatherhood. It's an ever-evolving journey that requires patience, understanding, and the willingness to grow alongside your children. Kekoa's stories and Madeline's reflections offer valuable lessons for all fathers striving to build strong, supportive, and empowering relationships with their daughters. As Dr. Christopher Lewis often reiterates, fatherhood is a journey for life—a journey best traveled with love, patience, and an open heart.   TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:16]: Welcome back to the Dads with Daughters podcast where we bring you guests to be active participants in your daughters' lives, raising them to be strong independent women. Really excited to have you back again this week. As always, I love being on this journey with you. We have an opportunity every week to be able to to to work through this journey that you're on with your daughter. And every week, I love being able to be on this journey. You know, I've got 2 daughters myself. I have the opportunity to be able to learn and grow just like you are from the guests that we have on the show because it is a constant journey that we are all on. No matter if you have infants or if you have college age or if you have kids that are grown and flown out of the house and living their own life. Dr. Christopher Lewis [00:00:54]: No matter what it is, you're still gonna be growing as a father, And your relationship with your daughters are going to change over that time. So it's important. It's important to keep learning, important to stay open to learning. And that's why every week I bring you different guests, different people that have gone through this journey in different ways. We have dads, we have daughters, we have lots of people with lots of different resources. And this week we got 2 great guests with us. I am always excited when I get to have a father and a daughter on. And this week, we do have that. Dr. Christopher Lewis [00:01:23]: We have father Kekoa Anderson, and daughter, Madeline Anderson, with us today. And Madeline and I got introduced because Madeline recently wrote a book called Girl Dad, Stories, Lessons, and Advice from Girl Dads and Their Daughters. And we'll talk a little bit about that and this. And I think we may even have this into a 2 parter. So we'll talk more in-depth about the book as well as what she learned. But today, we're gonna be talking a lot about their relationship and what led Madeleine to writing this book as well. So I'm really excited to have them on. Kikoa, Madeleine, thanks so much for being here today. Kekoa Anderson [00:01:56]: Thank you very much. Madeline Anderson [00:01:57]: Thank you for having us. Dr. Christopher Lewis [00:01:58]: It is my pleasure having you here today. And first and foremost, I wanna turn the clock back in time, Kikoa, and I'm gonna have you start here today. So I wanna go back to that first moment, that first moment that you found out that you were going to be a father to a daughter, what was going through your head? Kekoa Anderson [00:02:11]: Exciting times years ago. So, you know, going back to the time in my life, it was a great time in life. Just having been married for a number of years and dating my wife for some time. You know, that was the height of everything where life was all in front of me. So when that came, that was just kind of the first step of having a child. And my wife and I both wanted to be surprised, so we didn't know the sex of Madeleine at the time. So it was, you know, one of those things. And that day was just kind of life changing when all of a sudden this responsibility little package popped out and it was like really overwhelming, extremely positive way. Kekoa Anderson [00:02:47]: Reflecting back on that time was interest growing up and being a civil engineer and structural engineer and all the mechanics that are associated with that and testing everything, this was something where you could have a baby and walk out of the hospital and they just basically say, like, good luck. And there's no test, there's no form. It was an interesting time at that birth. So being ready for it, it's like, no, I was not ready for it. Nobody is. You just hear the stories from everybody. And so leaving that out, that was certainly a very exciting time. And then all of a sudden you realize, oh, I got a lot of work to do. Kekoa Anderson [00:03:20]: What's my plan and what's my path forward? Dr. Christopher Lewis [00:03:22]: You know, I talk to a lot of dads that talk about that moment when you're walking out of the hospital and they're they're especially if it's a first child, but also a your first daughter of this sense of heaviness that sets on you and the weight of being a father, but also of being a father to a daughter. And that there's some fear that goes along with that too. What would you say is was your biggest fear in raising a daughter? Kekoa Anderson [00:03:45]: It's almost like the from the little age, the fragileness and safety issue and kind of being there for him and, and the responsibility of like, of taking care of that life at that little time. It was, you know, that was the frightening part where, you know, it wasn't necessarily frightening, but it was just something that kind of came up on top. And then as you go through that, then those things change from protecting a helpless innocent little girl to then seeing her interact with certain situations, everything from preschool to kindergarten, where they had little discuss and there's little issues, which are easy solves at that time to when, you know, you move up into the junior high, high school range, and, you know, they start dating different guys, you know, then it becomes there's another kind of sense of where's the manual for this? And how do I interact with them and protect them guide them at the same time, give them the freedom to learn and choose and not be overwhelming. So you know, that very dynamic and changing all the way through it. So So now that you're interviewing me with an older daughter having gone through that, maybe I didn't answer the specific area. But, you know, that's kind of the from the start to where we were today, maybe in the summary. Dr. Christopher Lewis [00:04:50]: And, Madeline, when you hear that, what goes through Madeline Anderson [00:04:52]: your head? I'm just sitting here in awe. I mean, I know we've talked so much about our relationship and I interviewed him throughout the whole girl dad process, but I feel like every time I hear how he thinks and what's going through his head, it just reminds me of how many thoughts there are, how thoughtful he is, and just how incredible of a dad he is. But I think, yeah, as far as the fears and everything, I'm sitting here kind of imagining myself going through that with my own kids one day as well. And recognizing that, yeah, there's not just one big fear. I think you answered that really well, dad. It's it really evolves throughout time and changes depending on the age and the time of life and what's kinda going around them at the time. So I'm sure a lot of dads out there can relate to that as well. Kekoa Anderson [00:05:37]: Yeah. And it's it wasn't really so much fear. It was probably kind of the wrong word. It was just kind of a when I reflect back on it, it wasn't the number of fearful steps. It was just the situations came up. You weren't in fear waiting for it to happen. It just happened and you had to react. So it's like, how do you react when reactions are necessary? Dr. Christopher Lewis [00:05:55]: And I'll say it. I mean, and fear doesn't end. There are going to be things in life even when your child is out of the house and they are living their own life, that you can still be fearful or you can still have concerns. And but you have to temper those concerns and understand that your child is an adult. And how do you deal with that now, Kikoa, as you see Certainly Kekoa Anderson [00:06:17]: Certainly no fear of that, but there's, like, the worries and stuff. As I know, I feel very confident in her abilities to manage and take care of herself even from the safety issues to the work related elements to the financial side. Those, you know, at this level, it's nice. It's that's certainly a comfortable area where you can kinda boost control with that element instead of have to worry about it. But when challenges come up, certainly, you're there to go through those fears collectively and communicate them throughout. I still, as she's taken a trip to some area, I'm giving her extra fatherly advice on don't go to these parts and stay away from this or avoid that. And she probably doesn't wanna hear that. And she already knows anyway. Kekoa Anderson [00:07:01]: But it's also it's good just to throw those things out there. So those little bullet points are in her head. Head. I always do that, maybe overdo that too, which maybe is a negative, but, you know, it's my role. I have to do it. Dr. Christopher Lewis [00:07:12]: You're always gonna be a dad. That does not stop. No matter what and how old your child is, you'll still be a father and you're still gonna be engaged in many different ways. Now, every parent and then child are able to develop unique relationships, and there's things that really define that for themselves. Especially if you have multiple kids, you have to have those unique relationships with multiple kids. But when you have that relationship with your daughter, you're going to be developing it in your own way. Madeleine, for you, as you think about the relationship that you have with your dad and how that's evolved over the years, what's been some of the favorite things that you and your dad share together that you've appreciated most as you have gone through this relationship? Madeline Anderson [00:07:51]: Yeah. I would say to come to mind first. There's plenty of similarities and things that we bond over, but I would say the first one would be work. I was brought to my dad's work on the weekends when I was a kid, really enjoyed those moments. And he's always made me feel really included in his role and his job. And so I always understood when he was working, what he was doing, and it never felt like he was taking time away from me and my sisters. It felt like, oh, he's working. He's motivated. Madeline Anderson [00:08:21]: He's someone who we should be inspired by. So I always looked up to him in that sense. And then as I grew, I would always call him for work advice or business advice and we love bouncing ideas off one another or brainstorming things for work. So it's something that could be dry, but it's actually really fun for both of us, I think. And we have really great conversations around work and drive and what's next and game planning and goal setting and all of those kinds of things. And then number 2 would be golf. And that was something that my dad introduced to me as a young girl by just taking me to the course with him when he played with his friends. And at the time I didn't play, I just would sit there and count the bunnies and watch the wildlife and just enjoy myself in the cart. Madeline Anderson [00:09:06]: And finally, when I was old enough to maybe swing a club, I got a little snoopy set. It was a driver and a putter and one iron. And that was really fun for me because I felt included in the sport. And now, you know, he could take me with his friends and I could hit every now and then, and it made me feel like I was a part of the team. And then fast forward to high school, I tried out for the high school team and made that. And so I played throughout high school and he was always there guiding me. He would show up to my matches and had some fun little like one liners like roll it and hold it. And I'm forgetting some of the others, but there was some good life lessons. Kekoa Anderson [00:09:39]: From another. Madeline Anderson [00:09:40]: Yeah. Well, there's just some good life lessons in golf because it takes a lot of patience and we have to think about every stroke matters. Drive for show, putt for dough. That was another one you said. And it's just every stroke matters. You can't take what just happened in the past and apply it to the future. You have to take every single hit individually. And so having him there throughout that chapter was amazing. Madeline Anderson [00:10:03]: And now as an adult, I love going home and playing golf with my dad or trying to find a new course to play out with him. So that's been a really fun bonding experience that we still get to enjoy as adults and both work and golf, I suppose, that started when I was a young girl. Dr. Christopher Lewis [00:10:20]: And what about you, Kikoa? What were some of the things that you appreciated most in that building of the relationship and the things that you shared together? Kekoa Anderson [00:10:27]: That really makes my life takes me to that extra level. Like, if I didn't have a daughter or didn't have that area, like, how my life would be different. And definitely with 3 daughters, there was a lot of different uniqueness with each one and what we did. But specifically, I think some of the successes that really made my life more expanding was to include her in those things. With the work like one she talked about, you know, we've done a lot of different projects together. We kind of create the projects to work together on. And, you know, at a little age for her visiting the office and coming in and coloring and drawing on plan sets, you know, as an engineer and like developing bridges, we had all kinds of big sheets of paper. So that was a canvas to colour on, which was fun. Kekoa Anderson [00:11:10]: But at the same time, she got to kind of see, you know, what was all engaged. And there was a lot of neat things from the computers to the printers to even the old drafting elements that was kind of unique, you know, from the work and I think that helped guide her in some of the areas that she liked. But, you know, golf outside activity is an excellent sport to play with all 3 of my daughters and even my wife. It's just being out in nature and walking. Like I said, in the early age, it wasn't about her trying to outdrive her sister, that type of thing. It was like riding in the cart. You know, they wanted to drive the car, play with the bunnies, go to the lake and fish out golf balls or things more so. But then over time, it kind of grew. Kekoa Anderson [00:11:49]: So that walk together was really, you have time for conversation, Your daughter actually beats you on poles. So then you have the competition that's, I might drive longer, but she can putt better. So all of a sudden there's these equalizers that so having the competition and you're both trying your hardest is unique, you know, compared to some other sports. So, you know, I think we all enjoyed that time together. But even just the trips and things that we took and having the conversations is really what to understand who everybody is and how they're different and being able to engage in that. You just gotta make time to do that. So the more we did it, the better. And when there's times when we got caught up with other things, it's kind of rebalancing yourself so that you have time for those activities. Dr. Christopher Lewis [00:12:32]: You know, one of the questions that I guess that I would ask as a father of multiple daughters, as I said, you have to build those unique relationships. How did you find yourself parenting, fathering each of your daughters in unique ways to be able to build those unique relationships with each of them, as they were all growing? Kekoa Anderson [00:12:49]: Yeah. That's a tough one. I mean, that kind of first had a lot of activity. So it was like, here's kind of the spread. So as an engineer, I'm looking at economy of scale. So I want the golf clubs to pass down. So either one's gonna play golf. You know, the ski boots, it's like, hey, Malins went to Meredith, Meredith went to Ella. Kekoa Anderson [00:13:04]: And they I kept having 3 girls was awesome from a standpoint of once you kind of have all those upfront costs on the first, you can spread it down. But I think what we did was we were kind of well rounded and did a lot of different activities. So whether it was surfing, skiing, golfing, tennis, soccer, softball, pickleball, there was enough where we did a lot of sports, weren't necessarily experts in 1, but enjoyed the time together. So everybody kind of fell into their place and got to be themselves, you know, through that portfolio of a lot of different activities. Instead, you know, some fathers, maybe it's all soft ball and they only do softball and others might just be soccer and there's club and hockey now. And, you know, so everything's so focused and those coaches want you just to be like all this one sport. And they're always pushing for that for their team and their success. But again, watching the 3, maybe we wanted to make sure that they could go on the ski trip together. Kekoa Anderson [00:13:58]: And just because there was, you know, some club soccer team event that they would get in trouble for missing, it was kinda like we had to take that sacrifice so that our family could be together. So we didn't let, you know, one thing dominate, and we kept the portfolio open for the 3 to kinda fall into what worked Dr. Christopher Lewis [00:14:16]: best for them. Now, Madeleine, people can easily hear from you that you have been able you've been bothered in a good way in in regards to helping you to become a independent individual person that is out there living your life, doing good things, and really making a life for yourself ahead of you. And I'll say your parents had a say in that. They helped you in that journey, and you helped yourself in somewhat in that journey too. But I guess as you think back to the things that your father did, the things that he did to be able to help you to become the person that you are today, what were some of the things that really stand out to you that he did for you that really allowed for you to become the woman that you are today? Madeline Anderson [00:14:58]: The influence is certainly there. I think there's a couple of stories that come to mind, but I really liked what he said about the multiple sports. And I think that kind of mentality of, like, you can do whatever, find your passions, you know, it wasn't forced upon us, but we ended up like, I really enjoyed soccer and golf and my little sister, the littlest one, she found her passion in art. And I think throughout all of us kind of finding our own lane, obviously both my parents, my dad specifically has been so supportive and once once we kind of define what that lane is, he's really good about offering support and advice and kind of guiding us through that journey. But I think another thing is just that belief in me and my sisters and our capabilities. And one story that comes to mind is when I was 16, I just got my driver's license and my dad woke me up and he was like, Madeline, I'm double booked for a meeting. I'm I'm gonna need you to fill in for me. I was like, What do you mean? And he said, it's a pre proposal meeting. It's no big deal. You're gonna go there. You've got this. You just need to meet with everyone, give them your business cards, But first you need to understand if they're a landscape architect or an engineer. If they're an engineer politely, and the conversation move on, go to the next person, hopefully they're a landscape architect, then you give them your business card. And so I went to this pre proposal meeting. I was the youngest person by probably 30 years and one of the only women. Madeline Anderson [00:16:20]: And I had enough call, like probably too much confidence. And I just walked around and I was like, hi, would chat with somebody, found out they're a landscape architect, and then I would give them my business card. And then afterwards when I came home, even I was like, great job. Okay. Now follow-up with them. And I was like, what? So he taught me, he guided me through that whole process, but in doing so he gave me so much confidence in my abilities and put me in an uncomfortable situation, but told me that I was going to be great and could do it. And I think throughout that process, I learned how to be confident in my work and I'm sure that's just one example, but there's been so many throughout, especially high school and college where he's really just been there for me and, has guided me to feel confident about what I'm doing. So I I think that that's really translated into my adulthood and kind of how I do what I do. Dr. Christopher Lewis [00:17:09]: Thank you, Coop. Were there any other things that you intentionally tried to do with your daughters to be able to instill that in them, whether they accepted it or not? Kekoa Anderson [00:17:19]: Well, definitely, yeah. I mean, the whole point of challenging them to build their confidence is not giving them the answer to the question, but a number of questions to get to the answer. And through that path of finding those was part of that success of building the confidence. I think that was one area. You know, always look at a way to bait them into thinking through the process. And for example, if you go into that pre proposal meeting, I'm an engineer. We do the bridges. So we were looking we didn't need to meet them. Kekoa Anderson [00:17:47]: They're our competitors. We wanted to look at the ones that we could partner with. So her, you know, and it was low hanging fruit. If she messed up, it wasn't gonna change our outcome, but it was just a benefit. There wasn't the pressure of her having her having to fail. It was just giving her a chance to succeed. I mean, that step of kind of seeing if she could figure out a way to figure out who's the engineer, who's a landscape architect, because we wanted those landscape architects on our team. And if she messed up and actually got an engineer, we could've worked through that issue. Kekoa Anderson [00:18:14]: So, again, it was setting them up with a challenge and let them get their hands dirty and figure it out. Dr. Christopher Lewis [00:18:19]: Now we always finish our interviews with what I like to call our fatherhood 5, where we ask you 5 more questions to delve deeper into typically, it's the dad, but today, we're gonna be doing both of you. And so first and foremost, Madeline, in one word, what is fatherhood? Madeline Anderson [00:18:34]: I wanna say either guidance or support. Dr. Christopher Lewis [00:18:36]: Kekoa.? Kekoa Anderson [00:18:37]: Yeah. One word. That's a tough one. It's just kinda like it's life for me. It's like, hey. That's I'm a father. So that's a tough one. But it's definitely that walk. Kekoa Anderson [00:18:45]: It makes everything fatherhood is who I am. It's awesome. Love it. I can't imagine not being it and not having that. Dr. Christopher Lewis [00:18:51]: Now, Madeleine, when was the time that you felt that your dad finally succeeded at being a father to a daughter? Madeline Anderson [00:18:57]: I feel like the the finally is throwing me off because I think I grew up just with the understanding that he's a great dad to daughters. I don't know that there was ever a moment that it hit me. Oh, well, you know what? Actually, I will say when I went to college, that's when I really realized how amazing my dad is because I realized how rare that relationship is. And I might've taken it for granted, to be honest. And when I realized that a lot of the women around me did not have great relationships with their dads and they couldn't believe how close me and my dad are, that really shook me. And so, yeah, that would be probably the moment that I realized he has always been a great dad. Dr. Christopher Lewis [00:19:34]: and Kekoa? Kekoa Anderson [00:19:35]: Yeah. I mean, I think the success of being a father is is it's never over. It's, like, endless. So it's you're only as good as your last success. But some of the things where you know, I saw, you know, pivotal points and like, certainly like graduation and leaving the house. And interesting enough, like Malin writing this book, it was like because a lot of people don't get to talk about it. So then when I first was reading the drafts of that, it was like, you know, goodness, obviously, the things that I had forgotten about a number of things that we had done when she was young and those type of things and really getting her perspective. So if, I mean, if daughters made a list of things that they really appreciated and the dads got to see that, that's awesome. Kekoa Anderson [00:20:14]: And, you know, so that was kind of, you know, success by her writing that and me getting to reflect on it. You know, that was, you know, great job, Mandy. Dr. Christopher Lewis [00:20:23]: Thank you. And, Kikoa, as you think about fatherhood, who inspires you to be a better dad? Kekoa Anderson [00:20:27]: Yeah. I mean, that's a tough one too. I I think that my style is I watch and listen a number of people, and whenever I see a good idea or lesson learned, I I take that for myself. So, you know, certainly my father and my wife's father, they were great examples and a lot of family friends. So I kinda used that whole portfolio and sold all the great ideas for myself and step myself up based on what I saw and learned from them. So, but definitely, you know, my own father and my father-in-law were a big inspiration throughout the whole time as they were active with Madeline and the other daughters as well. Dr. Christopher Lewis [00:21:03]: Now, both of you have given a number of pieces of advice today, things that any dad could think about. As we finish up today, Madeline, what's one piece of advice you'd wanna give to every dad? Madeline Anderson [00:21:15]: I would say show up for her. And I think the best way to do that is by knowing who she is. So take the time to really understand your daughter, her passions, the way that she thinks, maybe her love language, and then use that information to show up for her the way that she needs because that's gonna look different for every daughter. Dr. Christopher Lewis [00:21:33]: Thank you, Koa. Kekoa Anderson [00:21:34]: Yeah. I think make the most of it and kind of, you get to reap all the benefits of it. I think that using golf is kind of one of the discussion items. There was a gentleman told me once, he said, you know, swing slow and accept the extra distance, which I always love that one, but that that's the same type of thing here with the advice for the dad. It's like there's a whole bunch of different moments and don't race to get to one end. Just enjoy the different parts of it and and kinda use that and take that time to engage. Dr. Christopher Lewis [00:22:02]: Well, I truly appreciate both of you sharing this today. And and I know, Madeleine, we're gonna have you on another episode to talk more about the book. We didn't go go really into the book today. We're gonna tease that out for the next episode that we're going to have with you to be able to delve even deeper into this learning of talking to all of these different fathers and not only kind of taking the the experience that you had with your own dad, but but going even deeper than that and talking to many other fathers about their own experiences. So I really appreciate you both sharing your journey and for sharing that with other dads, and I wish you both the best. Kekoa Anderson [00:22:40]: Thank you very much. Madeline Anderson [00:22:41]: Thank you, Christopher. Really appreciate you having us on today. Kekoa Anderson [00:22:44]: Indeed. Thank you so much. Dr. Christopher Lewis [00:22:46]: If you've enjoyed today's episode of the Dads with Daughters podcast, we invite you to check out the fatherhood insider. The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step road maps, and more. You will engage and learn with experts, but more importantly dads like you. So check it out atfatheringtogether.org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with daughters is a program of fathering together. Dr. Christopher Lewis [00:23:35]: We look forward to having you back for another great guest next week, all geared to helping you raise strong empowered daughters and be the best dad that you can be. We're all in the same boat, And it's full of tiny screaming passengers. We spend the time. We give the lessons. We make the meals. We buy them presents and bring your a game. Because those kids are growing fast, The time goes by just like a dynamite blast. Calling astronauts and firemen, carpenters, and musclemen get out and be the world to them. Be the best dad you can be.

Dr. Shaalan Beg and Dr. Arturo Loaiza-Bonilla discuss the potential of artificial intelligence to assist with patient recruitment and clinical trial matching using real-world data and next-generation sequencing results. TRANSCRIPT Dr. Shaalan Beg: Hello, and welcome to the ASCO Daily News Podcast. I'm Dr. Shaalan Beg, your guest host for the podcast today. I'm an adjunct associate professor at UT Southwestern's Simmons Comprehensive Cancer Center in Dallas and senior advisor for clinical research at the National Cancer Institute. On today's episode, we will be discussing the promise of artificial intelligence to improve patient recruitment in clinical trials and advanced clinical research. Joining me for this discussion is Dr. Arturo Loaiza-Bonilla, the medical director of oncology research at Capital Health in Philadelphia. He's also the co-founder and chief medical officer at Massive Bio, an AI-driven platform that matches patients with clinical trials and novel therapies.  Our full disclosures are available in the transcript of this episode.   Arturo, it's great to have you on the podcast today.  Dr. Arturo Loaiza-Bonilla: Thanks so much, Shaalan. It's great to be here and talking to you today.  Dr. Shaalan Beg: So we're all familiar with the limitations and inefficiencies in patient recruitment for clinical trials, but there are exciting new technologies that are addressing these challenges. Your group developed a first-in-class, AI-enabled matching system that's designed to automate and expedite processes using real-world data and integrating next-generation sequencing results into the algorithm. You presented work at the ASCO Annual Meeting this year where you showed the benefits of AI and NGS in clinical trial matching and you reported about a twofold increase in potential patient eligibility for trials. Can you tell us more about this study?  Dr. Arturo Loaiza-Bonilla: Absolutely. And this is just part of the work that we have seen over the last several years, trying to overcome challenges that are coming because of all these, as you mentioned, inefficiencies and limitations, particularly in the manual patient trial matching. This is very time consuming, as all of us know; many of those in the audience as well experience it on a daily basis, and it's resource intensive. It takes specialized folks who are able to understand the nuances in oncology, and it takes, on average, even for the most experienced research coordinator or principal investigator oncologist, 25 minutes per trial. Not only on top of that, but in compound there's a lack of comprehensive genomic testing, NGS, and that complicates the process in terms of inability to know what patients are eligible for, and it can delay also the process even further.  So, to address those issues, we at Massive Bio are working with other institutions, and we're part of this … called the Precision Cancer Consortium, which is a combination of 7 of the top 20 top pharma companies in oncology, and we got them together. And let's say, okay, the only way to show something that is going to work at scale is people have to remove their silos and barriers and work as a collaborative approach. If we're going to be able to get folks tested more often and in more patients, assess for clinical trials, at least as an option, we need to understand further the data. And after a bunch of efforts that happened, and you're also seeing those efforts in CancerX and other things that we're working on together, but what we realize here is using an AI-enabled matching system to basically automate and expedite the process using what we call real-world data, which is basically data from patients that are actually currently being treated, and integrating any NGS results and comparing that to what we can potentially do manually. The idea was to do multi-trial matching, because if we do it for one study, yeah, it will be interesting, but it will not show the potential applicability in the real world.  So with all that background, the tool itself, just to give you the punchline of it, was proven highly effective in terms of efficiency. We were able to increase the number of potential matches, and not only that, but reducing the time to the matching. So basically, instead of spending 25 minutes, it could be done in a matter of seconds. And when you compound all that across multiple clinical trials, in this case, it was several sponsors coming together, we were able to reduce the manual effort of seeing patients and testing for clinical trials to basically 1 hour when it would have otherwise taken a ridiculous amount of time. And it was quantified as 19,500 hours of manual work, compared to 1 hour done by the system to uniquely match a cohort of about 5,600 patients that came into the platform. And this was across 23 trials. Now imagine if we can do it for the 14,000 clinical trials currently in clinicaltrials.gov.   So for us, this kind of was an eye-opening situation that if we can increase not only the efficiency but find even more trials by integrating comprehensive genomic testing, which in this case was a twofold increase in eligibility for clinical trials, that gives us not only the opportunity for optimized processes using AI but also a call to action that there is still a lot of under-genotyping. And I know American Cancer Society and ASCO and many others are working hard on getting that into fruition, but we need to have systems that remind us that certain patients are not tested yet and that can improve not only real patients, but the R&D and the process of innovation in the future. Dr. Shaalan Beg: Yeah, it's always an important reminder that even some of the highest impact IT solutions or AI solutions are most effective if they can be integrated into our normal clinical processes and into the normal workflow that we have in our clinics to help clinicians do their work quickly and more efficiently. Can you talk about how, over the last few years, the availability of NGS data in our electronic medical record (EMR) has evolved and whether that's evolving for the better? And what are some next steps in terms of making that data available at EMR so that such solutions can then pull that data out and do clinical trial matching?  Dr. Arturo Loaiza-Bonilla: Yes. So one of the things that we have seen over the last couple of years is because of the applicability of the 21st Century Cures Act, there is less “information blocking,” which is patients not being able to access their information in real time. Now, with the appearance of health exchanges, with patient-centric approaches, which is something that many innovators, including ours, are trying to apply, it's really becoming more relevant. So it's not only helping us to find the patients when they really need to get tested, but also is giving us the opportunity to put those patients into the right treatment pathway when found. Something that's still a challenge and I think we can work by being more collaborative once again – is my dream – is having these pre-screening hubs where no matter where you are in your cancer journey, you just go into that funnel and then are able to see, “Okay, you are in the second-line setting for non-small cell lung cancer, EGFR-mutated. Now, do you have a meta amplification, then you go for this study or this trial. Oh, you haven't been tested yet. You should get tested. You're a pancreas cancer patient who is KRAS wild type; well, there is a significant chance that you may have a biomarker because that's where most patients are enriched for.” So having that opportunity to at scale, just for the whole country, to get those patients access to that information, I think is crucial for the future of oncology. And I think you working at the NCI, more than most, know how the impact of that can help for those underrepresented patients to get more access to better treatment options and whatnot. And we can activate clinical trials as well in new models, decentralized models, adjusting time models, all those things can be leveraged by using biomarker testing in real time. Identification when the patient really needs a trial option or a medication option, because the data is telling us when to activate that in real time. Dr. Shaalan Beg: And identifying the patient for a potential clinical trial is one challenge. In oncology, given a lot of our trials, we are looking to enroll people at a specific time in their disease journey. So we call it first-line or second-line or third-line, becomes the next challenge. So just knowing someone has mutation number 1, 2, or 3 isn't enough to say they would be eligible for a second-line BRAF X, Y and Z mutation at a given trial. I've heard you talk a lot about this last-mile navigation for people once you've identified that they may be a soft match for a clinical trial. Can you talk about what you've seen in the ecosystem being developed on how AI is helping both clinics and patients navigate this last mile from the time they're identified for a clinical trial to the time they actually receive cycle 1, day 1? Dr. Arturo Loaiza-Bonilla: Yeah, absolutely. And that is such a critical point because, as you know, we have helped tons of patients getting trial options in thousands of cases. But even my own patients, I give them a report for trial options and they're like, “Okay, I still need help.” And we have been talking with ASCO, with the American Cancer Society, and many other very good teams, and what we see as an opportunity in technology here is leveraging those cancer journeys to know when the patient really has the opportunity to enroll in a trial, because this is a very dynamic environment. Not only the patient's condition changes because their cancer progresses, the hemoglobin changes, the cancer moves from one place to the other, and there's nuances in between, but also new medications are coming up, studies open and close, sites open and close.  So having this information as a hub, as what we call a command center, is the key to make this happen. And we can use the same tools that we use for Uber or for Instacart or whichever thing you want to do; it's already the same concept. When you need groceries, you don't need groceries every day. But Amazon gives you a ding that's like, “Well, I think you may be running out of milk,” because they already know how often you buy it, or just having the data behind the scenes of how typically these, in this case, patient journeys, may manifest based on the biomarker. So let's say a smoldering multiple myeloma is not the same across. One patient with biomarkers that make them very high risk, the risk of progressing to a multiple myeloma, first-line treatment-eligible patient is going to be much different than someone who has better risk cytogenetics. So using that tool to optimize the cancer journeys of those patients and being able to notify them in real time of new trial options, and also knowing when the patient really has that disease progression so there's a time of activation for trial matching again, the same way you get a credit score for buying a house, then you know exactly what options are in front of you at that very moment. And that is the last-mile component, which is going to be key. What we have seen that we feel is important to invest on, and we have invested heavily on it, is that until the patient doesn't sign the consent form for the clinical trial, that patient is completely unknown to most people. The site doesn't know them because they haven't been there, and they may be there, but they don't know about the options sometimes. But no one's going to invest in getting that patient to the finish line. There's a lot of support for patients on trials, but not before they enroll on trials. And we feel that this is a big opportunity to really exponentially grow the chances of patients enrolling in trials if we support them all the way from the very time they get diagnosed with cancer in any setting. And we can help that patient on a very unique journey to find the trial options using technology. So it's very feasible. We see it once again in many other equally complex tasks, so why not do it in oncology when we have all the bonafides across wanting to do this. Dr. Shaalan Beg: Can you give examples of where you are seeing it done outside of oncology that's a model that one can replicate? Dr. Arturo Loaiza-Bonilla: I mean, oncology is the toughest use case to crack. You have experiences with DCTs in the past and all that. So the big opportunities are for patients, for example, in psychiatry, when they need certain counseling and help. We see that also in medical devices, when people have diabetes and they really need a device specifically for that unique situation, or also for patients with cardiovascular risk that they can in real time get access to novel therapeutics. And that's how they have been able to enroll so quickly. And all these GLP-1 inhibitors, all those models are really almost completely decentralized nowadays in something that we can extrapolate for oncology once we have aligned the ecosystem to make it see them. This is something that we can really revolutionize care while we manage all the complex variables that typically come with oncology uses.  Dr. Shaalan Beg: I would imagine while you translate those learnings from outside of oncology into oncology, a lot of those processes will be human and AI combination activities. And as you learn more and more, the human component becomes a smaller fraction, and the technology and the AI becomes more of a component. Are you seeing a similar transition in the clinical trial matching space as well? Dr. Arturo Loaiza-Bonilla: Yes. So that's why people say humans are going to be replaced. They're not. Patients still want to see a human face that they recognize, they trust. Even family members of mine want to hear from me, even if they are in the top place in the world. What we can change with technology are those things that are typically just friction points. In this case, information gathering, collecting records, getting the data structured in a way that we can use it for matching effectively, knowing in real time when the patient progresses, so we can really give them the chances of knowing what's available in real time. And collecting the information from all these other stakeholders. Like, is the site open? Is the budget approved for that place? Is the insurance allowing the specific … do they have e-consent? Those things can be fully automated because they're just burdensome. They're not helping anyone. And we can really make it decentralized for e-consent, for just getting a screening. They don't need to be screened at the site for something that they're going to receive standard of care. We can really change that, and that's something that we're seeing in the space that is changing, and hopefully we can translate it fully in oncology once we are getting the word out. And I think this is a good opportunity to do so. Dr. Shaalan Beg: You talked about your dream scenario for clinical trial matching. When you think about your dream scenario as a practicing oncologist, what are the AI tools that you are most excited about making their way into the clinic, either wishful thinking or practically? Dr. Arturo Loaiza-Bonilla: I typically get feedback from all over the place on doing this, and I also have my own thoughts. But I always come to this for a reason. We all became physicians and oncologists because we like being physicians. We like to talk to patients. We want to spend the time. I tell folks in my clinic, I will see a thousand patients all the time as long as I don't have to do notes, as long as I don't have to place orders. But of course, they will have to hire 1,000 people ancillary to do all the stuff that we do.  If we can go back and spend all that time that we use on alert fatigue, on clicking, on gathering things, fighting insurance, and really helping align those incentives with clinical trials and biomarker testing and really making it a mankind or a humankind situation where we're all in this really together to solve the problem, which is cancer, that will be my dream come true. So I don't have to do anything that is clerical, that is not really helping me, but I want to use that AI to liberate me from that and also use the data that is generated for better insights. I think that I know my subject of expertise, but there's so many things happening all the time that it is hard to keep up, no matter how smart you are. If the tool can give me insights that I didn't even know, then leverage that as a CME or a board certification, that would be a dream come true. Of course, I'm just dreaming here, but it's feasible. Many of these ideas, as I mentioned, they're not new. The key thing is getting them done. The innovative part is getting stuff done, because I'm sure there's a gazillion people who have the same ideas as I did, but they just don't know whom to talk to or who is going to make it happen in reality. And that's my call to action to people: Let's work together and make this happen. Dr. Shaalan Beg: Well, Arturo, thanks a lot for sharing your insights with us today on the ASCO Daily News Podcast. Dr. Arturo Loaiza-Bonilla: Well, thank you so much for the time and looking forward to having more exchanges and conversations and seeing everyone in the field. Dr. Shaalan Beg: And thank you to our listeners for your time today. You'll find a link to the studies discussed today in the transcript of this episode. And if you value the insights that you hear on the 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. Arturo Loaiza-Bonilla @DrBonillaOnc   Follow ASCO on social media: @ASCO on Twitter   ASCO on Facebook   ASCO on LinkedIn     Disclosures:    Dr. Arturo Loaiza-Bonilla: Leadership: Massive Bio Stock and Other Ownership Interests: Massive Bio Consulting or Advisory Role: Massive Bio, Bayer, PSI, BrightInsight, Cardinal Health, Pfizer, Eisai, AstraZeneca, Regeneron, Verily, Medscape Speakers' Bureau: Guardant Health, Bayer, Amgen, Ipsen, AstraZeneca/Daiichi Sankyo, Natera   Dr. Shaalan Beg:    Consulting or Advisory Role: Ispen, Cancer Commons, Foundation Medicine, Genmab/Seagen    Speakers' Bureau: Sirtex    Research Funding (An Immediate Family Member): ImmuneSensor Therapeutics    Research Funding (Institution): Bristol-Myers Squibb, Tolero Pharmaceuticals, Delfi Diagnostics, Merck, Merck Serono, AstraZeneca/MedImmune

Exploring Values-Driven Fatherhood In a recent episode of the Dads with Daughters podcast we sat down with Dr. Jason Frishman of JourneyMen to delve into vital conversations surrounding fatherhood, societal equity, and the evolving role of dads in modern families. From building equitable homes to redefining traditional masculinity, this episode offered profound insights and practical advice for every father aiming to be more present and effective in their children's lives. Below, we unpack the most compelling segments from their conversation. The Roots of Social Justice in Family Life Dr. Jason Frishman shared how his upbringing, influenced by deeply rooted values of equality and social justice, shaped his perspectives on parenting. The lessons he learned from his grandparents and parents about fairness and understanding have become the foundation of how he raises his own children. Jason emphasized that fostering an equitable home environment isn't only a moral obligation; it's essential for nurturing well-rounded, empathetic individuals. Concerns Over Societal Pressures One of Jason's primary concerns lies in the societal pressures that could impact his children's values and character as they grow. He pointed out that while more men are spending time at home, the growth in fatherhood roles hasn't kept pace with these changes. This lag can lead to challenges as men navigate roles they may not be fully prepared for, often under the weight of traditional societal expectations. Transitioning from Children to Fathers: A Professional and Personal Journey Jason's professional journey has taken him from working with children to specializing in counseling men and fathers. This shift was driven by his passion for creating positive societal change and challenging the traditional narratives of masculinity. He introduced the concept of "foundational adventures," a counternarrative designed to redefine what it means to be a man and a father in today's world. Embracing New Masculinity Narratives Journeymen, the organization Jason is involved with, seeks to redefine masculinity and fatherhood. By promoting more inclusive partnerships at home, Journeymen encourages fathers to be active, engaged, and supportive partners, paving the way for healthier family dynamics. Jason's personal realization of embedded patriarchal thoughts highlighted the need for continuous growth and change, both individually and collectively. Values Work as a Beacon for Personal Growth A crucial part of Jason's message is the role of values in guiding personal growth. He stressed that challenges and conflicts shouldn't be seen as roadblocks but as opportunities for learning and development. For fathers seeking to make meaningful changes, Jason advises starting with a clear vision of what they want their household and relationships to look like, then identifying and overcoming the barriers that stand in their way. The Universal Chaos of Parenting Dr. Christopher Lewis underscored that parenting is a shared experience, often chaotic and busy but profoundly rewarding. Likening it to managing a boat full of "tiny screaming passengers," Dr. Lewis emphasized the importance of being actively involved in all aspects of children's lives—from spending quality time, imparting lessons, and preparing meals, to celebrating special moments. This hands-on approach is essential for building strong father-daughter relationships. A Call to Action for Fathers Both Dr. Lewis and Dr. Jason Frishman called on fathers to be intentional and present in their children's lives. Jason suggested that being a better father and partner involves becoming a stronger, more grounded individual. Overcoming obstacles requires a clear understanding of one's values and the dedication to addressing what hinders their achievement. Intentional Parenting: Building Connections and Having Fun Jason also highlighted the significance of intentionality in parenting. This involves using language consciously, allowing children to have a voice in their upbringing, and ensuring that parenting decisions align with core values. Moreover, he stressed the importance of having fun and enjoying time with family, as these moments create lasting bonds and cherished memories. The Fatherhood Five: Embracing Connections and Small Gestures In the 'Fatherhood Five' segment, Jason shared his personal reflections on fatherhood, describing it as fundamentally about connections. He prides himself on the close relationship his sons share and hopes they would describe him as silly, optimistic, and caring. Jason finds inspiration from his sons, wife, parents, and a close group of male friends, and he holds steadfast to the advice of consistently showing love through small, intentional actions. Dr. Dr. Jason Frishman's insights on the Dads with Daughters podcast offer a compelling vision for modern fatherhood—one rooted in equity, intentionality, and joy. By embracing these principles, fathers can create nurturing environments that foster positive growth and deep connections with their children. To engage more with Jason's work or to access resources on effective fatherhood, visit the Journeymen website or reach out via the contact details provided in the podcast episode. Dr. Jason Frishman was a part of Sarah Maconachie's book of stories about fathers called Working Dads and Balancing Acts.  TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:16]: Welcome back to the Dads with Daughters podcast where we bring you guests to be active participants in your daughters' lives, raising them to be strong, independent women. Really excited to have you back again this week. Love being able to be on this journey with you, knowing that you know that I've got 2 daughters. I know that you have daughters. And it is a great opportunity for us to walk on this path together because the journey that I am on is not going to be the same journey that you're on, but we have similarities. There are things that we go through that are similar, and we can learn and grow from each other, and we can learn and grow from other fathers that are doing fatherhood in a little bit different way. We can push ourselves to be able to get out of our comfort zone. We can push ourselves to do something different, to be that engaged father, that more present father that we want to be. Dr. Christopher Lewis [00:01:10]: And that's why the show exists. The show exists so that every week, you have an opportunity to take what you're learning and put it into action, to be able to hear from others that have gone before you that are doing fatherhood in a little bit different way, that have different resources that are available to you and can help you in that journey that you're on. So thank you. Thank you for being here. Thank you for being back every week. And I love being able to bring you different guests that are going to be able to help you in different ways. And this week, we got another great guest with us. Doctor. Dr. Christopher Lewis [00:01:42]: Jason Frischman is with us today. And Doctor. Frischman is a father of 2 sons, but he also works with men that are struggling to balance work and family and that are working to become more confident, connected, and fully alive. And we're gonna talk about that. We're gonna talk about the journey that he's been on as a father, and I'm really looking forward to talking to him today. Jason, thanks so much for being here today. Dr. Jason Frishman [00:02:06]: Excellent. Thank you so much. I'm really glad and looking forward to our conversation. Dr. Christopher Lewis [00:02:10]: Well, I'm excited to have you here today as well. And first and foremost, I wanna turn the clock back. I know you've got some teenagers in the house right now, and I would love to turn the clock back. I said I did say you had sons. So I wanna go back to that first moment that you found out that you were gonna be a father to a son. What was going through your head? Dr. Jason Frishman [00:02:29]: It's a powerful and important question. We didn't find out that the baby was gonna be a son until he was born. And actually his birth story was a really hard one. And so because of everything that was going on, we were planning a home birth and it was all picture perfect and beautiful until it wasn't. And then we wound up in the emergency room at the hospital. And frankly, when I found out he was a boy, that I was having a son, it was the least of my concerns. And we were just so very happy that he was healthy, that my wife was healthy. He fortunately didn't need to spend time in the NICU. Dr. Jason Frishman [00:03:03]: And so the first and foremost was we have a healthy baby. And the next piece was once it hit that we you know, I had a son. And at that time in my life, working as a psychologist, I worked even then primarily with males, male identifying clients. And so I think when Micah was born, I think I was nonplussed in terms of gender, but I also was like, well, I'm kind of an expert in that, so maybe it'll be easier. Flash forward, it it hasn't been, but that's besides the plight. But the other piece is and this happened more when we had our second son because I think we knew we were only gonna have 2, but having 2 sons, we knew that we have a big responsibility in terms of raising good boys. That is something that I've spent my entire career helping others to do, and it sort of became our turn. And so I think both my wife and I have felt like we were meant to raise good men, and that's why we have 2 sons. Dr. Jason Frishman [00:03:57]: But we also feel in our risk this responsibility that boys and young men in this culture, they have a lot of work to do. And so we our values and who we are as both humans and parents and friends and etcetera, we wanted our children to be raised a little bit differently. Part of your introduction about, like, parents who do it a little differently. That was a big part of the intention that we have in every developmental stage of our kids' lives. Dr. Christopher Lewis [00:04:23]: So talk to me about parenting a little differently. How do you define that, and what have you tried to do in your sons' lives to parent differently and to allow for them that that difference to be in their life in that regard? Dr. Jason Frishman [00:04:36]: Well, I think the first piece, which sounds very simple and yet has always been very challenging and something that we stay aware of is a lot of what we do, we want to be intentional. Intentionality and transparency are 2 of our common values as parents. And so I'll give a good example. Both my wife and I are trained as narrative therapists. And so in the narrative therapy world, language is very important. We believe that language and stories help derive and and drive reality. Right? And so the language that we use, even when our kids were pre verbal, was very intentional. So for example, at the time, when my first born son was was was born, we made the decision that I would continue working and seeing clients and my wife would stay home. Dr. Jason Frishman [00:05:19]: Now, on the one hand, that is a very typical traditional gender split, but because we are intentional about it, it changed the way we had to talk about what that was like. And so a great example is even when my son was preverbal as an infant, we never used the language of papa's going to work, and we corrected others when they said that. Right? Papa's going to the office. Right? Because saying that I'm going to work, what does that say about my wife who's staying home? Right? And so we were very intentional about the fact that, you know, she was doing more, you know, work if not, you know, as much if not more work than I am. And so we never wanted that language to to build a, a sort of a schema for for our kids where father goes to work, mama stays home. Right? And so intentionality around the language we use, intentionality around, the the products, the the things that we do with our kids, that was always very important. Another another good example is that, you know, I'm big at both of us are big in the food world. I I've been a cook and a chef and I've taught I've used it. Dr. Jason Frishman [00:06:36]: We've had small businesses with food and, you know, food values are very important to us. And so my wife who has been a a vegetarian since 14, she said, most vegetarians choose to be vegetarian. We're raised as omnivores or carnivores, and we choose to be vegetarian. We chose to raise our kids as vegetarian. And when they showed that they sort of understood the values and the ideas and the morals that we were sharing, then they could make their own choice. And right now, both of my kids have chosen to eat meat. My wife actually has started eating meat, and yet we're very intentional. Like at this point, we only eat meat if we know the farmer. Dr. Jason Frishman [00:07:16]: And in Vermont, we can do that. But most of the time when we go out, we said tell we we're vegetarian because we can't do it otherwise. So these are sort of mundane but important examples. But in terms of parenting differently, we're very intentional, transparent. We're aware of our language and the language we use, especially around gender with our kids. And then the other part is we're very, like I said, transparent. So my kids have always had a voice. Not that, you know, we're the adults and we're in charge, but my kids have always had a voice in in kind of what we do, how we do it. Dr. Jason Frishman [00:07:53]: They are able and and comfortable to give me feedback. I ask for it as the parent, as the father. And so sometimes I don't always like that, but it but but I but I always welcome the fact that they can tell me or share with me what I'm doing, how that makes them feel, and what it makes them think about. And it gives them a voice and agency and empowers them to grow into themselves in the boundaries that we as the parents have set. Dr. Christopher Lewis [00:08:22]: So talk to me about that intention. And not every father, not every man has gotten to that point where they are doing the same thing or that they are trying or working to build a equitable home in regards to what is happening inside their own home. And we definitely don't see the equity being rewarded from a societal end. So personally, and it may go back to how you were raised, what made you personally decide as a man, as a father, as a husband, that that was important to you and that you wanted to instill that in your own children, and you wanted to break the the societal cycle, let's say, that is out there? Dr. Jason Frishman [00:09:10]: Wow. That one question we could spend, you know, a lot of time on, but two things. You hit the nail on the head in terms of it does start with my own upbringing and childhood. I would start even with my mother's parents, who've sadly recently both passed away. They were partners in the truest sense of the word. Even as a child, I remember that. The 2 of them sat down and did the taxes together. My grandmother, in a time when that didn't really happen, she was as aware of the money and the investments and that, you know, she was as aware of that, if not more than my grandfather. Dr. Jason Frishman [00:09:43]: And they were real partners. There's a great story is my grandfather drove me to college when I graduated high school. My parents were working. And I recently asked, I said, was grandma there? Did she go too? And my mom was like, of course, they did everything together. They were real partners. So that was the model I got from my grandparents. My parents, very, very similar. At one point, my mom went back to grad school and said, if y'all wanna eat, you better learn how to cook. Dr. Jason Frishman [00:10:07]: And my father learned how to cook. And so I always witnessed this sort of working towards equality and working towards an awareness of how we are at home and how the society at large is, and just the strength and courage it takes to do things differently. So that has always been a part of the way I look at the world. And then of course, you know, I I grew up trained as a psychologist. I try I got my master's and my doctorate and was always leaning. I used to joke that as a psychologist, I'm sort of a social worker in psychologist clothing. I have always been someone who looks towards social justice and equality and has been impacted by the inequality and the the sort of oppression and challenges that are led. And then, because of my working with boys and men for so many years, I'm a white man in this culture. Dr. Jason Frishman [00:10:56]: And having the background that I have, that has all become very prominent. And really, I find it to be one of the most vital issues in our culture today is the level that patriarchy has damaged both men, boys, and subsequently, every you know, families. And so it has become a real passion of mine to work for equality and just intentionality in the way that we use language and and work with gender. Dr. Christopher Lewis [00:11:23]: So as you think about raising your sons, and as you talked about, you're raising your sons in a different way and challenging them and pushing them and encouraging them in different ways in the way that they are being raised. As you look at your biggest fear in raising them today? When I was young, my mom do you remember the 2? Fear in raising them today? Dr. Jason Frishman [00:11:44]: When I was young, my mom do you remember the TV show Family Ties? Yep. So when I was young and I was a very liberal, even more so than my parents, progressive kind of thinker, all these things, my mom used to tease me that I was gonna get an Alex P. Keaton furissa. And that's not my worry. I don't think that's gonna happen. But I do worry that the strength and presence of my kids is going to be battered at from a larger society. I mean, we have purposefully, like, you know, my kids have been in a bubble. Like we encourage childhood in a very solid way. Dr. Jason Frishman [00:12:18]: And we live in a rural town in a small state that is very white. And, you know, we've done our best to expose them to the world, and we talk politics. You know, we share things with them. But I guess my my my, one of my big fears or worries is that when they go out into the world, will they have enough of a solid foundation to stand on when they're hit with much of the mainstream ethos and pathos, you know, frankly. How will they hold up? Now, if the way they say it up to me is any indication, I think we'll be fine. But I do worry sometimes that the the sort of mainstream masculine way of being expectations and roles will beat them down a little bit. Dr. Christopher Lewis [00:12:58]: I appreciate you sharing that. Now I mentioned at the beginning that you work with men and that you are working with them, with individuals that are struggling to balance work and family and be connected and confident and helping them to, as I said, fully alive. Talk to me about how you got into this work and why you decided that working with men and creating journeymen was something that was a passion area and was something that you really wanted to focus on? Dr. Jason Frishman [00:13:31]: So I've been a therapist. I've been as a psychologist, I've been working for about 25 years, and almost exclusively with boys, men, and families. And when I started my career, I'm naively embarrassed to share that I started my career and said I'm always gonna work with kids because if you're an adult and you're a jerk, it's too late for you. Now that is really naive to say, you know, 25 years later, I'm embarrassed that that was my way of thinking. I was saying that to justify that I love working with kids, but I had my own kids and I really wanted to save my sort of child energy for my kids and the community that we have. So I started working with older men and eventually sort of landed on men and fathers as a way of working. And as that was developing, as I was then specializing in learning and doing a lot of research on masculine psychology and sociology, you know, all of these things. I also simultaneously was going through a change in the narratives that I work with, that I love. Dr. Jason Frishman [00:14:26]: So you may have heard of the hero's journey. It is a narrative that is sort of ubiquitous in our culture. It's all the the Pixar movies, Star Wars, Lord of the Rings, all of these things. I love that narrative. I wrote my dissertation from the metaphor of that narrative, and it probably was 85 to 95% of all of the interventions, questions, and and work that I did was based around a really in-depth learning of the hero's journey. That said, about 15 years ago, something hit me. Part of narrative therapy is this idea of questioning taken for granted stories. So in professional honesty, I had to question my own favorite narrative, the hero's journey. Dr. Jason Frishman [00:15:04]: Long story short, I actually now feel that although I still love The Hero's Journey, it's actually not complete. And the fact that it is so omnipresent is actually quite damaging to boys and men. And the fact that our primary narrative models tell us that we either have to be epic or legendary in order to be worthy is really troubling and damaging to men who, most men who are going to work and coming home and you know, doing the dishes and things like that. And so the challenge or the the passion part of developing journeyman came from working more and more with men and fathers and finding how powerful that work was. It came from developing a counternarrative to the hero's journey, which I now call foundational adventures. And it came to this idea of like listening to men who, you know, may be super successful at work, but then they come home and they're lost. They come home and they're stuck. They come home and where's my place? There's a fact, a detail that I remember reading somewhere. Dr. Jason Frishman [00:16:01]: I won't use the exact numbers because I'll get it wrong, but there is a large amount of men who are largely spending more time at home than ever before, which we might think, hey. That's wonderful. And it is. But there's also hasn't been the equal amount of growth and development for father about what to do when they're at home. So that they're staying more at home. Some guys are getting it lucky and doing well and and being real present to their kids. But many men are staying at or or at home more with their kids, but coming at it with the same mindset mentality and social training that we've had for the last 100 years, which means that they're at home more and there's more opportunities to make trouble or mistakes or propagate this sort of mindset. And so the idea for me is that Journeymen was, how do we write new narratives for masculinity and fatherhood that involve and include a partnership at home and honor going and battling dragons or being off at work doing things and really developing deeper, more meaningful stories for men who just like everyone else on the planet, need emotional connections, strong deep depth of relationships, and love, frankly. Dr. Christopher Lewis [00:17:11]: And talk to me about over the years, you've been doing this journeyman work since 2019 when you started things. And I'm sure over the time and over working with men in this work that you learned a lot more about men, but also more about yourself. And talk to me about that. And what have been some of the biggest takeaways for yourself as a father, a husband, a man that you're putting now into place in your own life and some of the things that you're learning about the work that you're doing and some of the biggest struggles that men are struggling with? Dr. Jason Frishman [00:17:46]: The front of mind answer around learnings for me personally that I'm learning from the work and then bringing it home and then bring it back to the work deep in it is none of us are done. I think I'm pretty conscientious. I'm pretty aware. You know, all of these things, and I am. And yet recently, my wife and I had a huge argument about something that was very based in sort of sexism, very based in my unwillingness to be open to a partnership, ideal. And frankly, initially, when she said it that way, I was offended. Like, I wasn't open. I do this work every day. Dr. Jason Frishman [00:18:21]: And, you know, all of a sudden, I'm getting called out for something. And once I breathed, once I, like, let it sort of settle a little bit, it was really powerful for me to say, okay, you're right. Some of this patriarchal thought or dominance based culture, however we wanna talk about it, is so deeply embedded in all of us. And so for me, it's that there's always growth, potential, and possibility. And I've been using this statement a lot both at work and at home, but the magic and the treasure is in the muck. There's this narrative. There's this story in our culture that it'll be good when. As long as I get to blank or once I turn blank, you know, like, once I get to the end, it'll be better. Dr. Jason Frishman [00:19:00]: And I think there's such a problematic ideology there. And so a lot of it is in the muck, in the marshes, in the trouble. That's where the magic is. That's where the treasure is. And so one of the best learnings that came from that that I bring back to the work at Journeyman is we do a lot of values work. You know, let's learn what's important to us. And I do something called the values compass. It's an exercise where we pick 4 values that are can be visibly expressed, that I can see, right? Not this big ethereal, vague value, but something that is real can be specific. Dr. Jason Frishman [00:19:36]: And I have the guys pick 4 values that are inherently connected to the goal, the treasure that they're working on. And we put them in a compass. Well, what we've started to talk about in addition to the magic is in the muck is that our values are both the directional points and the steps on your path on your journey and the treasure. So if I'm following my values, number 1, I know the right direction and choices to make. But number 2, if I'm following my values, I'm feeling better. I'm doing better. I'm acting better. So I've actually achieved my goal on the way towards achieving my goal. Dr. Jason Frishman [00:20:14]: And so that you're always going up and down with that. It's a challenge and it's it's terribly difficult to live your values in the everyday. And so when we're doing it, let's recognize it and say, oh, I found a treasure. I've hit a goal. Now it's time to get back to it because I gotta keep walking. I'm in the muck. Right? And so it's nothing new. It's nothing some it's not an insight that I think I've developed. Dr. Jason Frishman [00:20:34]: I mean, Buddhists have lots of people have used it forever. I think there's a saying, no mud, no lotus. That's in a saying. Same kind of thing is that our challenges, our arguments, our conflicts are is always an opportunity for growth, and that's where the treasure is. Dr. Christopher Lewis [00:20:47]: I love that. And I love that statement because I think you're completely right. I mean, there is a lot of muck that we go through in being fathers and being men. I guess one of the questions that I would have for you in the work that you're doing is there are going to be fathers that have not worked with you, but are thinking to themselves, you know what? There's some things that we that I could maybe be doing here based on what Jason's saying. What are some initial steps, some things that they could do right now today that could get them moving in at least the right direction? It may still mean that they wanna work with you down the road, but at least to have either an internal dialogue or have something that will allow for them to push themselves in the right direction in this regard. Dr. Jason Frishman [00:21:30]: I think the first step and and I have guys do this early on in the work anyway, and I I it's I think it's really important. There's there's 2 different things to become aware of. The first is what do we want? And I can blow that out. What kind of father do I wanna be? What kind of sons or daughters do I wanna raise? Not that I have much control over that, but in an ideal sense, what would I like to give to my kids? What kind of legacy do I wanna to share with them? What kind of values do I want to do I want to exist in my household? And really taking a look at what I would like that to be. How I would like do I want a household where after dinner, everybody's sitting on the same couch looking at their phones? Do I wanna have a household where everybody goes back to their rooms and does whatever, but we're not connected? Do I wanna have some mixture of that, but also, like, I don't know, we're playing board games at night or whatever, but, like, real specific, what do I want my household, my home to look like? And how do I want the relationships of the people who I purport to love the most? How do I want them to be? So I want first to ask men, how do you get clear on that? Do you want to spend your time tinkering in the garage or do you wanna be with the kids? Do you want what do you want? Do you want more intimacy with your wife? I had one guy who joined Journeyman said, I want my kids to be as comfortable holding my hand at 22 as they are at 12 and that they were at 2 and he said doesn't have to be literally holding my hands, but metaphorically, I want them to have that same level of comfort throughout their life. And that was his goal. That was his treasure. So I wanna encourage fathers to think about what are the ongoing relational goals that they have in their home, with their partner, with their kids, with themselves. Dr. Jason Frishman [00:23:15]: So that would be step 1. And step 2 would be, what's getting in the way? And it's time to be radically honest with yourselves, guys. Right? What is getting in the way? Let's just use the example of not wanting everyone to be on their own phones and to be dialoguing or spending time together or doing something. What's really getting in the way? Starting with you and the other adults in the house. If you look at yourself, a lot of journeymen, a lot of the work there, I always am very explicit. It's not a parenting group. We talk about parenting. We talk about that. Dr. Jason Frishman [00:23:43]: It's not about getting your kids to eat vegetables or go to bed on time, or learn to drive the car responsibly. It's men's work. It's about you being a stronger, more present, grounded man who can be in relationship, who can be in partnership. And so with that, you're gonna be a better father. You're gonna be a better partner. You're gonna be a better, more present to everything that's going on. So to answer your question more succinctly is get it clear with what you want at home and get clear about what you really give a shit about and what's getting in the way. What's getting in the way? What are the obstacles? Right? Are you too tired? Are you too stressed? Are you is your own pattern to isolate when things happen? Is your own pattern to get reactive? What is the thing that keeps you from those goals that you're looking for and name it. Dr. Jason Frishman [00:24:26]: Can't tell you how important that is. Once you name the obstacle, you have some control over it. And I've had clients who, once they identify it, really understand it and give it a name, I've had clients tell me like, oh my god, things are so much better. Just because they start to notice and they start to give something a name, you have some power. So those would be the 2 steps that I would suggest anyone can start to get a handle on before even getting into this work more deeply. Dr. Christopher Lewis [00:24:48]: Well, I appreciate you sharing that because I think it is a journey and definitely something that will take time and effort, and you may have to get out of some bad practices or bad ruts that your family might have gotten into, especially over COVID or other aspects that change things. You know, you may have to make some adjustments within your home and really think deeply about where you want to be, where you are right now, as Jason already said. Now, Jason, we always finish our interviews with what I like to call our fatherhood 5, where I ask you 5 more questions to delve deeper into you as a dad. Are you ready? Dr. Jason Frishman [00:25:22]: Before you start, can I add one thing? It'll be very quick. I am realizing I'm reflecting even on what I said, and it all sounds very heady and up here. More importantly or most importantly is, like, having some fun. I think so much of what men do is we go to work, we come home, we discipline, we but have fun with your family. Like, you love them. Have fun with them. And I just think that so much of the work, while it has this real heady, deep depth underground, a lot of the work, especially at Journeyman, is around fun. It's around metaphor. Dr. Jason Frishman [00:25:53]: It's around being silly. It's around all those things. And so I can't emphasize that enough is that men need to be having more fun. So anyway, the fatherhood 5 we can get into, but I didn't wanna not say that. Dr. Christopher Lewis [00:26:03]: In one word, what is fatherhood? Dr. Jason Frishman [00:26:05]: Connections. Dr. Christopher Lewis [00:26:06]: When was the time that you finally felt like you succeeded at being a father? Dr. Jason Frishman [00:26:10]: I watch my 2 sons being friends. They're 3 and a half years apart and they're buddies. They really are. And they admit it. They like to admit it. They'll argue like other brothers, but they are close. And I watch them. My parents did the same thing, but I, my wife and I always said, we would love for our boys to be aligned together even more than they're aligned with us, and truly they are. Dr. Jason Frishman [00:26:31]: And so that that's a success. That's a big win for me. Dr. Christopher Lewis [00:26:34]: If I were to talk to your sons, how would they describe you as a dad? Dr. Jason Frishman [00:26:38]: It depends on the day. I think they would say that I'm silly. I am annoyingly optimistic and positive. I love to cook and I love to take care of them. Dr. Christopher Lewis [00:26:49]: Who inspires you to be a better dad? Dr. Jason Frishman [00:26:51]: Well, they do for 1, for sure. My wife does. My own parents do. And I'm really fortunate, actually. I have a close group of male friends. And the depth of friendship that I with them is unusual. And I don't take it for granted, but all of them are either fathers or uncles and are good men. And so there's a mutual, like, love, respect, and inspiration in terms of doing better. Dr. Christopher Lewis [00:27:13]: You've given a lot of pieces of advice today, things for people to think about and to delve a little bit deeper into their own psyche and themselves to figure out kind of where they're at and where they wanna be. But as we finish up today, what's one piece of advice you'd wanna give to every dad? Dr. Jason Frishman [00:27:28]: Hug and kiss your kids and say the words I love you. I mean it, of course, but I think the small actions count. I think the piece of advice is really hug, kiss, and saying I love you can be lots of things, but the small intentional and consistent actions are more important than any grandiose gesture that you can do. We're working at a long term deep foundation. And so if you want your kids to be the kind of humans that you're hoping for and to have a relationship for life, then play the lifelong game. And so small, consistent, intentional actions are really the way to go. Dr. Christopher Lewis [00:28:06]: Now we talked about Journeyman. We talked about the work that you're doing. If people wanna find out more about you, about Journeymen, where's the best place for them to go? Dr. Jason Frishman [00:28:13]: The 2 places. First is I live on the website, so journeymenfoundation dotcom. The other piece is right now, I say sometimes we, but it's really me. So if you email jason@nourished connections.com, you'll get me directly. And I I really enjoy connecting with people who are either fathers or who love fathers and wanna be supportive. And so those are the 2 most direct ways, but I'm also on social media. I'm on Facebook, Instagram, LinkedIn. And one thing that I would offer is, and I can send you a link afterwards, is I did put together this sort of it's the 10 fastest, most effective ways that fathers can connect with their kids. Dr. Jason Frishman [00:28:49]: And it's all about the small, consistent actions. I do every single one of them. So this isn't just something I write about. I'm also the president. And so I can send the link to that and people are more than welcome to as soon as you when you go to that link, you can download that copy. Every single one on there, I think I timed it once. If you did all 10, I think there's a bonus 11. But if you did all 10, it's less than 12 minutes every day. Dr. Christopher Lewis [00:29:11]: I love it, and we'll definitely add it to the notes today and add it in so everyone can take 10 minutes to reconnect and to better connect with your kids. Jason, I just wanna say thank you. Thank you for being here today, for sharing your journey, and I wish you all the best. Dr. Jason Frishman [00:29:27]: Oh, thank you so much. This has been great. I really appreciate it. Dr. Christopher Lewis [00:29:29]: If you've enjoyed today's episode of the dads with daughters podcast, we invite you to check out the fatherhood insider. The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step roadmaps, and more, you will engage and learn with experts, but more importantly, dads like you. So check it out at fathering together.org. If you are father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with daughters is a program of fathering together. We look forward to having you back for another great guest next week, all geared to helping you raise strong and powered daughters and be the best dad that you can be. We're all in the same boat, and it's full of tiny screaming passengers. We spend the time. We give the lessons. We make the meals. We buy them presents and bring your AK. Because those kids are growing fast. The time goes by just like a dynamite blast. Calling astronauts and firemen, carpenters, and musclemen. Get out and be the world to them. Them. Be the best dad you can be.

Dr. Allison Zibelli and Dr. Erika Hamilton discuss the results of the DESTINY-Breast06 trial in HR+, HER2-low and HER2-ultralow metastatic breast cancer and the A-BRAVE trial in early triple-negative breast cancer, the results of which were both presented at the 2024 ASCO Annual Meeting. TRANSCRIPT Dr. Allison Zibelli: Hello, I'm Dr. Allison Zibelli, your guest host of the ASCO Daily News Podcast. I'm an associate professor of medicine and breast medical oncologist at the Sidney Kimmel Cancer Center of Jefferson Health in Philadelphia. My guest today is Dr. Erika Hamilton, a medical oncologist and director of breast cancer research at the Sarah Cannon Research Institute. We'll be discussing the DESTINY-Breast06 trial, which showed a progression-free advantage with the antibody-drug conjugate trastuzumab deruxtecan (T-DXd) compared to chemotherapy in hormone receptor-positive HER2-low or HER2-ultralow metastatic breast cancer. We'll address the implications of this study for the community, including the importance of expanding pathology assessments to include all established subgroups with HER2 expression, and the promise of expanding eligibility for antibody-drug conjugates. We'll also highlight advances in triple-negative breast cancer, focusing on the A-BRAVE trial, the first study reporting data on an immune checkpoint inhibitor avelumab in patients with triple-negative breast cancer with invasive residual disease after neoadjuvant chemotherapy.  Our full disclosures are available in the transcript of this episode.  Erika, it's great to have you on the podcast today. Dr. Erika Hamilton: Thanks so much, Allison. Happy to join. Dr. Allison Zibelli: Antibody-drug conjugates are rapidly changing the treatment landscape in breast cancer. The data from the DESTINY-Breast06 trial suggests that trastuzumab deruxtecan may become a preferred first-line treatment option for most patients with HER2-low or HER2-ultralow metastatic breast cancer after progression on endocrine therapy. First, could you remind our listeners, what's the definition of HER2-ultralow and what were the findings of this trial? Dr. Erika Hamilton: Yeah, those are fantastic questions. Ultralow really has never been talked about before. Ultralow is part of a subset of the IHC zeros. So it's those patients that have HER2-tumor staining that's less than 10% and incomplete but isn't absolutely zero. It's even below that +1 or +2 IHC that we have classified as HER2-low. Now, I think what's important to remember about D-B06, if you recall, D-B04 (DESTINY-Breast04) was our trial looking at HER2-low, is that D-B06 now included HER2-low as well as this HER2-ultralow category that you asked about. And it also moved trastuzumab deruxtecan up into the frontline. If you recall, D-B04 was after 1 line of cytotoxic therapy. So now this is really after exhausting endocrine therapy before patients have received other chemotherapy. And what we saw was an improvement in progression-free survival that was pretty significant: 13.2 months versus 8.1 months, it was a hazard ratio of 0.62. And you can ask yourself, “well, was it mainly those HER2-low patients that kind of drove that benefit? What about the ultralow category?” And when we look at ultralow, it was no different: 13.2 months versus 8.3 months, hazard ratio, again, highly significant. So I think it's really encouraging data and gives us some information about using this drug earlier for our patients with hormone receptor-positive but HER2-negative disease.  Dr. Allison Zibelli: I thought this study was really interesting because it's a patient population that I find very difficult to treat, the hormone receptor-positive metastatic patient that's not responding to endocrine therapy anymore. But it's important to mention that T-DXd resulted in more serious toxicities compared to traditional chemotherapy in this study. So how do you choose which patients to offer this to? Dr. Erika Hamilton: Yeah, those are both great points. So you're right, this is after endocrine therapy. And in fact, about 85% of these patients had received at least 2 prior lines of endocrine therapy. So I have some people kind of asking, “Well, if endocrine therapy really isn't benefiting everyone in the second-line setting post-CDK, should we just move to the ADCs?” And, no, probably we should really make sure that we're exhausting endocrine therapies for those patients that are going to benefit. And once we determine somebody has endocrine-resistant disease, that's when we would think about switching. In terms of the side effects, I think you're right. It's mainly ILD that's probably the more serious side effect that we worry about a little bit with trastuzumab deruxtecan. The good news is, through multiple trials, we've gotten a little bit better at managing this. We've pretty much all but eliminated any fatal cases of ILD, definitely less than 1% now. ILD rates, depending on what study you look for, kind of ranges in that 10% to 15% range. Any grade ILD on D-B06 was 11.3%. So really kind of making sure that we look for ILD at scans, making sure that patients are educated to tell us about any new pulmonary symptoms: cough, exertional dyspnea, shortness of breath at rest, etc. But I think the most common side effects that we really deal with on a daily basis with trastuzumab deruxtecan, luckily, is nausea, which we've gotten better at managing with the 2- or 3-drug antiemetic regimen, and probably a little bit of fatigue as well. Dr. Allison Zibelli: Thank you. So, I think for most people in the community, the sticking point here will be expanding pathology assessments to include all of the subgroups, including the ultralow. Most patients in the community are not testing for HER2-low and HER2-ultralow now. Dr. Erika Hamilton: Historically, we kind of all did HER2 IHC, right? And then as FISH became available, there were a lot of institutions that moved to FISH and maybe didn't have IHC anymore. And now, at least in my institution, we do both. But I think it's a very important point that you made that IHC was really designed to pick out those patients that have HER2-high, the 3 pluses or the FISH amplified cases. It was not to tell the difference between a 1+ or a 2+ or a 0 that's not quite a 0 and a 1+. So I think you're right. I think this is tough. I probably have a little bit more of an interesting take on this than some people will. But data from ASCO, not this year but in 2023, there was actually a pretty eloquent study presented where they looked at serial biopsies in patients, and essentially, if you got up to 4 or 5 biopsies, you were guaranteed to have a HER2-low result. Now, this didn't even include ultralow, which is even easier. If we know we include ultralow, we're really talking about probably 85% to 90% of our patients now that have some HER2 expression. But if we biopsy enough, we're guaranteed to get a HER2 low.  And so I think the question really is, if we know IHC wasn't really designed to pick out these ultralows, and we know kind of greater than 90% of patients are going to have some expression, did we kind of develop this drug a little bit backwards? Because we thought we understood HER2, and the reality is this drug is a little bit more like a sacituzumab govitecan, where we don't test for the TROP2. Should we really be kind of serial biopsying these patients or should maybe most patients have access to at least trying this drug?  Dr. Allison Zibelli: So I don't think that most of my patients will really be happy to sign up for serial biopsies. Dr. Erika Hamilton: Agreed. Dr. Allison Zibelli: Do we have any emerging technologies for detecting low levels of HER2? You talked about how the IHC test isn't really designed to detect low levels of HER2. Do you think newer detection techniques such as immunofluorescence will make a difference, or will we have liquid biopsy testing for this? Dr. Erika Hamilton: Yeah, I think liquid biopsy may be a little bit hard, just because some of those circulating tumor cells are more of a mesenchymal-type phenotype and don't necessarily express all of the same receptors. Normally, if they're cytokeratin-positive, they do, but certainly there is a lot out there looking at more sensitive measures. You mentioned immunofluorescence, there are some even more quantitative measures looking at lower levels of HER2. I definitely think there will be. I guess, ultimately, with even the IHC zeros that are the less than 10% incomplete staining, having a PFS that was absolutely no different than the HER2 low, I guess the question is, how low can we really go? We know that even the IHC zeros doesn't mean that there's no HER2 expression on the cell surface. It just means that maybe there's a couple of thousand as opposed to 10,000 or 100,000 copies of HER2. And so it really appears that perhaps this drug really is wedded to having a lot of HER2 expression. So ultimately, I wonder how much we're going to have to use those tests, especially with what we know about tumor heterogeneity. We know that if we biopsy 1 lesion in the liver, biopsy a lymph node, or even another lesion in the liver, that the HER2 results can have some heterogeneity. And so ultimately, my guess is that most people have some HER2 expression on their breast cancer cells. Dr. Allison Zibelli: So maybe we're going to be using this for everybody in the future. Dr. Erika Hamilton: It certainly seems like we keep peeling back the onion and including more and more patients into the category that are eligible to receive this. I agree. Dr. Allison Zibelli: Let's move on to triple-negative breast cancer, namely the A-BRAVE trial. This was an interesting trial for patients that did not get neoadjuvant immunotherapy and testing 2 groups. The first group was those with residual disease after neoadjuvant conventional chemotherapy. The second group was people with high-risk disease identified upfront that had upfront surgery. The study found that adjuvant avelumab did not improve disease-free survival versus observation, which was the study's primary endpoint. But interestingly, there was a significant improvement in 3-year overall survival and distant disease-free survival. Can you give us your thoughts on that? Dr. Erika Hamilton: Yeah, I think this study was really interesting. Right now, the standard for our patients with larger or node-positive triple-negative cancers is KEYNOTE-522. It's a pretty tough regimen. It's kind of 2 sequential uses of 2 chemotherapies, so 4 chemotherapy agents total with pembrolizumab. But you're right, this study looked at those that had residual disease after neoadjuvant that didn't include immunotherapy, or those patients that didn't get neoadjuvant therapy, went to surgery, and then were receiving chemotherapy on the back end. I'm going to give you the numbers, because you're right. The 3-year disease-free survival rates were not statistically significant. It was 68.3% among those that had avelumab, 63.2% with those that had observation only. So the difference was 5.1% in favor of avelumab, but it wasn't statistically significant. A p value of 0.1, essentially. But when we looked at the 3-year overall survival rates, we saw the same pattern, those patients with the avelumab doing better, but it was 84.8% overall survival and not, unfortunately, dying, versus 76.3%. So the magnitude of benefit there was 8.5%, so about 3% higher than we saw for disease-free survival, and this was statistically significant.  So is this going to change practice for most patients? I probably don't think so. I think for our patients that have larger tumors that's recognized upfront or have node positivity, we're probably going to want to use neoadjuvant chemo. Being able to get a PCR is very prognostic for our patients and enables us to offer things on the back end, such as PARP inhibitors or further chemotherapy of a different type of chemotherapy. But for our patients that go to surgery and maybe the extent of their disease just isn't recognized initially, this could be an option. Dr. Allison Zibelli: I agree. I think this will be a really useful regimen for patients where we get the surprise lymph node that we weren't expecting, or somebody who comes to us, maybe without seeing the medical oncologist, who got upfront surgery. So I thought this was really interesting. What kind of translational studies do you think we're going to do to try and understand which patients would benefit from avelumab? Dr. Erika Hamilton: Yeah, I think that's a great question, and honestly, it's a question that we haven't really answered in the neoadjuvant setting either. Immunotherapy in breast cancer is just a little bit different than it is in some other diseases. We have a benefit for those patients that are PD-L1 positive in the first line. We really haven't seen benefit for metastatic outside of first line. And then in neoadjuvant, it was among all comers. We don't have to test for PD-L1. And now we have this avelumab data from A-BRAVE. I think the question is, is there's probably a subset of patients that are really getting benefit and a subset that aren't. And I don't know that PD-L1 testing is the right test. We know a lot of people are looking at TILs, so kind of lymphocytes that are infiltrating the tumor, a variety of other kind of immunologic markers. But my guess is that eventually we're going to get smart enough to tease out who actually needs the immunotherapy versus who isn't going to benefit. But we're not quite there yet. Dr. Allison Zibelli: Thank you, Erika, for sharing your valuable insights with us on the ASCO Daily News Podcast today. Dr. Erika Hamilton: Thanks so much for having me.  Dr. Allison Zibelli: And thank you to our listeners for joining us. You'll find the links to all the abstracts discussed today in the transcript of this episode. Finally, if you like this podcast and you value our insights, please take a moment to rate, review, and subscribe wherever you get your podcasts. It really helps other people to find us. So thank you very much for listening today.   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. Allison Zibelli Dr. Erika Hamilton @ErikaHamilton9   Follow ASCO on social media:  @ASCO on Twitter    ASCO on Facebook    ASCO on LinkedIn      Disclosures: Dr. Allison Zibelli:  None Disclosed   Dr. Erika Hamilton: Consulting or Advisory Role (Inst): Pfizer, Genentech/Roche, Lilly, Daiichi Sankyo, Mersana, AstraZeneca, Novartis, Ellipses Pharma, Olema Pharmaceuticals, Stemline Therapeutics, Tubulis, Verascity Science, Theratechnologies, Accutar Biotechnology, Entos, Fosun Pharma, Gilead Sciences, Jazz Pharmaceuticals, Medical Pharma Services, Hosun Pharma, Zentalis Pharmaceuticals, Jefferies, Tempus Labs, Arvinas, Circle Pharma, Janssen, Johnson and Johnson   Research Funding (Inst): AstraZeneca, Hutchison MediPharma, OncoMed, MedImmune, Stem CentRx, Genentech/Roche, Curis, Verastem, Zymeworks, Syndax, Lycera, Rgenix, Novartis, Millenium, TapImmune, Inc., Lilly, Pfizer, Lilly, Pfizer, Tesaro, Boehringer Ingelheim, H3 Biomedicine, Radius Health, Acerta Pharma, Macrogenics, Abbvie, Immunomedics, Fujifilm, eFFECTOR Therapeutics, Merus, Nucana, Regeneron, Leap Therapeutics, Taiho Pharmaceuticals, EMD Serono, Daiichi Sankyo, ArQule, Syros Pharmaceuticals, Clovis Oncology, CytomX Therapeutics, InventisBio, Deciphera, Sermonix Pharmaceuticals, Zenith Epigentics, Arvinas, Harpoon, Black Diamond, Orinove, Molecular Templates, Seattle Genetics, Compugen, GI Therapeutics, Karyopharm Therapeutics, Dana-Farber Cancer Hospital, Shattuck Labs, PharmaMar, Olema Pharmaceuticals, Immunogen, Plexxikon, Amgen, Akesobio Australia, ADC Therapeutics, AtlasMedx, Aravive, Ellipses Pharma, Incyte, MabSpace Biosciences, ORIC Pharmaceuticals, Pieris Pharmaceuticals, Pieris Pharmaceuticals, Pionyr, Repetoire Immune Medicines, Treadwell Therapeutics, Accutar Biotech, Artios, Bliss Biopharmaceutical, Cascadian Therapeutics, Dantari, Duality Biologics, Elucida Oncology, Infinity Pharmaceuticals, Relay Therapeutics, Tolmar, Torque, BeiGene, Context Therapeutics, K-Group Beta, Kind Pharmaceuticals, Loxo Oncology, Oncothyreon, Orum Therapeutics, Prelude Therapeutics, Profound Bio, Cullinan Oncology, Bristol-Myers Squib, Eisai, Fochon Pharmaceuticals, Gilead Sciences, Inspirna, Myriad Genetics, Silverback Therapeutics, Stemline Therapeutics

A Heartfelt Conversation In the latest episode of the Dads with Daughters podcast, we welcome Gerard Gousman to explore the unique experiences and challenges he faces as a father of four sons. Gerard shares his heartfelt insights and practical advice, making this episode a must-listen for every dad striving to be the best parent they can be. Let's dive into the critical themes and topics discussed during their engaging conversation. Reflecting on the Initial Stages of Fatherhood Gerard Gousman opens up about his initial reactions to becoming a father. The mix of excitement, fear, and overwhelming responsibility is something many new dads can resonate with. "It's like stepping into a world where you have no previous experience," says Gerard, reflecting on the early days of fatherhood. As he navigated through sleepless nights and constant second-guessing, Gerard began to understand the profound and rewarding nature of being a dad. The Dynamics of Parenting at Different Stages Parenting isn't a 'one size fits all' journey, and Gerard underscores this by discussing the differences in parenting toddlers, preteens, and teenagers. He highlights the importance of flexibility and adaptation, learning to adjust his parenting style to each child's unique needs and communication preferences. By doing so, Gerard has been able to maintain close relationships with his kids, fostering an environment where they feel safe and understood. Embracing Technology and Remote Living With the shift to remote work and education, Gerard speaks on the challenges and opportunities this new dynamic brings. Living in a more remote setting has highlighted the importance of balancing screen time with physical activity and real-world interactions. Gerard emphasizes finding creative solutions to keep his children engaged and active, such as outdoor adventures and tech-free family time. The Pressures and Expectations of Fatherhood One of the most relatable aspects of Gerard's story is his fear of not meeting the high standards and expectations of modern fatherhood. "There's always this lingering worry—am I doing enough?" Gerard admits candidly. Over time, he learned that striving for perfection isn't sustainable. Instead, he focuses on being present and consistent, realizing that it's the simple, everyday moments that matter most. Creating Wins and Building a Cool Dad Reputation A shining light in Gerard's journey is his 'cool dad' win at the trampoline park. Taking his 7-year-old and a friend out for some jumping fun led to high praise from the friend, labeling Gerard as the "coolest dad at school." This moment encapsulates the joy of being an involved parent and solidifies Gerard's belief in the importance of participating in his children's interests. Finding Inspiration and Support Gerard draws inspiration from his children's growth and positivity and from other supportive dads who share their journeys. He emphasizes the importance of finding a community, whether through local groups or online platforms. These connections offer a sense of belonging and a wealth of shared knowledge, making the challenges of fatherhood feel less isolating. Advice for New Dads: Stay Happy and True to Yourself To new fathers, Gerard offers sage advice: "Don't lose yourself after becoming a father. Your happiness is crucial for your family's well-being." He encourages dads to pursue their interests and maintain their personal happiness, which in turn creates a more joyful and balanced family environment. Transitioning Careers for Family Gerard's decision to transition from a high-pressure career in the event management and music industry to being a stay-at-home dad speaks volumes about his commitment to his family. He discusses the fear of missing out (FOMO) and the challenges of shifting focus from an active social lifestyle to home life. Parenthood required him to reevaluate his priorities and embrace a new, fulfilling role. Navigating Family Dynamics and Individual Needs Understanding that each child is unique, Gerard keeps notes on his children's favorite things to use as points of connection when other communication methods fail. This personalized approach has helped him navigate tough conversations and strengthen his bond with each child. Advocating for At-Home Dads Gerard has become a vocal advocate for at-home dads, participating in a New York Times article to challenge stereotypes. His efforts have been met with positive responses from friends and other fathers, underscoring the value of representation and community. The Role of Community in Fatherhood Finding a supportive Fatherhood community, like the National At Home Dad Network and local dad groups, has been instrumental in Gerard's journey. He emphasizes the importance of reaching out and connecting with others who understand and appreciate the unique challenges and rewards of fatherhood. The Simple Joys of Fatherhood For Gerard, fatherhood in one word is "amazing." It's the little victories, the shared laughs, and the opportunity to watch his children grow that make the journey so rewarding. As he continues to adapt and learn, Gerard remains a beacon of positivity and strength for his family. In summary, Gerard Gousman's journey is a powerful reminder that fatherhood, with all its ups and downs, is an ever-evolving adventure. His insights and experiences provide invaluable lessons for dads at any stage, encouraging them to embrace the journey with an open heart and a flexible mindset.   TRANSCRIPT Dr. Christopher Lewis [00:00:05]: Welcome to dads with Daughters. In this show, we spotlight dads, resources, and more to help you be the best dad you can be. Dr. Christopher Lewis [00:00:16]: Welcome back to the dance with daughters podcast where we bring you guests to be active participants in your daughter's lives, raising them to be strong, independent women. You know, every week, I love being able to sit down and talk with you, to work with you, to help you on this journey that you're on. Each one of us is on a unique journey. And you have daughters, I have daughters, but we learn from each other. We learn from others. And the more that we're willing to step out and hear what others have to say, step out and take in that learning, take in what others have to say, the more that you're going to be able to be that engaged dad, and that father that you want to be to your children. And that's why every week I bring you different guests, different people with different perspectives and, and different from different walks of life that have gone through either fatherhood in a different way have different resources that they can share. And I love being able to do that. Dr. Christopher Lewis [00:01:10]: Because, as I said, each one of us is on a unique journey, but we can learn from each other and we can help each other along the way. This week, we got another great guest with us. Gerard Guzman is with us today. Gerard is a father of 4 sons. And you might be saying, well, this is the dads with daughters podcast. Why are we having a father of sons here? Well, there's a reason and we're gonna be talking about that. Gerard went through his own journey as a working dad that made some choices, made some choices to be that active, engaged dad that he wanted to be and may have made some choices that you might have made or might not have made. We're gonna talk about that. Dr. Christopher Lewis [00:01:47]: And I'm really excited to have him here, be able to share his story, learn a little bit more about him. Gerard, thanks so much for being here today. Gerard Gousman [00:01:53]: Thanks for having me.  Dr. Christopher Lewis [00:01:54]: It is my pleasure having you here today. Love being able to have you on and being able to learn more about you. 1st and foremost, I love being able to start the podcast with the opportunity to go back in time, get in the in that proverbial time machine. I want to go all the way back. I know you've got kids that range from 22 months all the way to 22 years. So I want to go back maybe 23 years, I want to go back to that first moment that you you found out that you were going to be a father. What was going through your head? Gerard Gousman [00:02:19]: For the first time, I was young. I was in college scared, excited, hopeful. It was there from was the experience of not knowing what was ahead of me, but, like, alright. Trying to figure out, alright. How can how do I do this? How do I be a dad? And I look at the examples of examples around me and okay. To figure out how long if I take a little piece of pieces of this from the different dads I know and trying to grab what I thought was right. And, of course, none of us do it right. It's from the start. So got that knocked myself off, knocked my dust myself off, and got back up and keep trying it again and again until some point in the next couple weeks. I think I may get it right. Dr. Christopher Lewis [00:02:55]: I'll have to check back with you in that few weeks and see if you actually hit that point because I don't know if any of us do it right all the time. And we definitely stumble, fall, pick ourselves back up, as you said. And our kids are gonna be the first ones to point out when we make mistakes. So that's definitely the case. Now, as I said, you've got kids that range from 22 years to 22 months. And with each and every child, you have to parent in a little bit different way. And you've learned things along the way, but you've got a very young child and a child that's potentially out of the nest in regards to grown, flown, starting his adult life now. So talk to me about what you've learned along the way and how you're parenting your 22 month old now differently than you may have parented your 22 year old. Gerard Gousman [00:03:44]: Yeah. It's definitely a much different world now, physical world and just my immediate world where I'm coming from then being young and my experience, all things that come with being a young adult in a big city and trying to do that. And it was also at the time of really starting. I was in music and college and working in marketing. Just Just starting out working in marketing in events and just trying to navigate and figure out what I was gonna be and what I was gonna do. And some of the experiences I have always been of the mind is bring trying to do as much as you can to marry marry my worlds together. I was trying to bring the kids out into the events and never use that having kids excuse to not be able to do something that you probably could do with them. That's something I've always tried to maintain with of showing my kids as much of the world and as many different experiences as I can. Gerard Gousman [00:04:39]: And still to this day doing that, but a bit differently, plus the mix of technology, and we're a little more remote than we were then. And starting out, I was with in Chicago, it's so close to a lot of family. But now remote here in the on the West Coast, and most of my family is still Midwest and back east. So it's completely different raising the family, raising kids away from the family, and not having a strong of a communal family support. Dr. Christopher Lewis [00:05:06]: Now you mentioned at the beginning when you first had your first child, you were definitely a little bit scared. And I think there's some fear that goes along with every father, Whether you have daughters, whether you have sons, in some aspect, when you bring a new child into the world, there's always some fear. What was your biggest fear in being a father? Gerard Gousman [00:05:22]: A lot. I think of not being able to hold up to the standards that I had, I guess, as a kid, like, what the ideal dad was. Like, when I grow up, when I have kids, I'm never gonna yell, and I'm gonna always be there, and I'm always gonna be smart, and I'm gonna trust my kids and know all the things that you wanted as a child from your parents. I'm like, I'm gonna be that parent. Like, how do I hold up to be that parent that I wanted as a kid? And then I realized, like, that's not realistic. You you quickly learn, like, oh, that's why they were always tired. That's why they were always yelling. Like, in retrospect, that was very dangerous. It's finding that out that I could try to bring in those parts of me that I wanted to mold and have my parenting style being able to live up to that standard. Dr. Christopher Lewis [00:06:13]: Now with the fact that your children are at different points, different ages, different experience levels, and you look at that fear now in regard to what you've gone through. Is the fear that you have as a father different for your 22 month old in the life that he will have versus the fear that you have now for your adult son? Gerard Gousman [00:06:35]: Think of are you thinking in in time that learn to be a lot more flexible and not take not take the losses as hard. And sometimes, like, I take the stumbles as much. I mean, there's simply times where you do everything you can and things don't work out, but you say, alright. Didn't work out this time. How do I learn from this experience and use it to parent better down the road? So going back to things I thought of with now with my now 7 year old being the 1st grader and thinking back to when my oldest was in that age and trying not to put as much pressure, like, that pressure to be the best student and be the nicest kid and be perfect in public and be respectful. Be always be as respectful as possible and and to try to keep them as polished they could. And now being a point of letting them breathe and kinda learn their own way and instilling those the same principles in them, but not instilling the pressure as much. I wanna know that, yeah, it's okay to take those missteps and but being able to be open and and be able to come back to us as parents and know that we have that support level of support that I don't think I instilled in my kids, in my older kids when they were younger. Gerard Gousman [00:07:52]: It's kinda that these are your benchmarks. You gotta hit them. You gotta hit them. And now it's like, alright. If you don't, that's okay. We can find a way to make up the gap. Dr. Christopher Lewis [00:08:00]: And kinda chuckling to myself because I think as you go through life as a parent, and I I could just imagine your oldest son saying to you, you were so much harder on me and you kept me to a different standard than than you're holding to my younger siblings. And you do. You know, it's not that you're favoring one than another, but you learn. And as you said, you become more laid back, I believe. The more fathers that I talk to, the more kids that they have, I think the more laid back they do become. Gerard Gousman [00:08:28]: Yeah. And then the thing of knowing how like, in the beginning, you don't know what the outcome or outcomes be, but outcomes will be. But as it goes on, you kinda you understand the patterns. You see the algorithm of life. And, like, okay. I know where before I had to make the 6 or 7 steps. I know that 2 or 3 of those steps weren't really important and kinda slowed things up. So now being able to have been able to more fine tune things in real time and just being more aware of those benchmarks that we like I said before about trying to hit those and not it's not always the most important thing. Sometimes the trying is enough. Dr. Christopher Lewis [00:09:03]: Now I know that or you, as you said, you were a employee for many years, you worked out in the world, doing event management, Salt N Pepper, Cat Power. I mean, lots of artists that were out there. You were traveling a lot, and at some point, you made a decision. You made a decision that some changes need to be had, and you needed to be closer to home. You needed to be able to be more a part of the family. Talk to me about that internal conversation you had to have, the conversation you had to have with your wife as well to think about this in a different scenario that made you make some choices that were going to substantially change your life and change your family's life? Gerard Gousman [00:09:50]: Yeah. Well, I think into that point, it was sitting around the birth of my 3rd, and the 2nd one's went through, and it was kinda wandering in between, I guess, seasons. I guess the way the event seasons go, it's kinda like the tail end and starting I don't know. I wanted to be there and support my wife as much as I could that and doing the beginning of the maternity leave and school being able to really be a part of the moments, all of the pre visits and all that stuff and really having the excitement of the pregnancy. That's not that I missed out by. My other 2 was just, like, being out on the road and traveling and not being able to be there for the earliest moments. And once it got to that point of, like, seeing it, I knew I could be there. And one of the things made it a lot easier is is the decision to be able to support my wife in her career. Gerard Gousman [00:10:38]: And she she was on the upper trajectory. And Shrunkar Bennett really got into a point where she was really making strides and wanted to be able to support her in that and give that example for the kids as well. Like, I know I could do this and with cards on the table and look to see what our strengths were. It's like, yeah. I I can do this and give you that so you need to go back and focus on your career and or can I can hold it down here and still be able to do things that I needed to do for myself? And when it I think I've built a strong relationship with my wife, and we are to the point that we are very open communicators in regards to what our immediate needs are. Like, we tend to check-in with each other, and where it may not be something long gone or drawn out, we know when something's not right and, like, always we try to stay on the same page much as possible. And I think that helped make the transition a lot easier, just knowing that I can instill a system, and we have our routines in the house, and it makes us it could be able to flow. And we are able to still have a lot of the things that we loved about life before. Gerard Gousman [00:11:41]: Like, we're avid campers, and we like to travel. And being able to do that stuff with the kids while they're young, I think, has been great for me. Like, definitely a lot of those day to day, like, month to month, the growing things, like, being able to notice little height differences. Like, that arm's longer than it was a few weeks ago. And having full conversations with the baby, and actually, like, because I'm with because I'm with him, I understand what he's saying. And so you're having those things that priceless and suits so valuable, and, like, I know you never get that time. It's really knowing the value of the time. It's been more valuable than however much I would have made out there in the field. Dr. Christopher Lewis [00:12:21]: So talk to me a little bit about that transition, that transition from work at work outside of the house, traveling, working in the industry, working with artists, you know, that high pressure, high paced life to transitioning to home and being that stay at home dad where you're running the household, keeping things running while your wife is working on her career. What was the hardest part for you in making that transition? And what were some of the things that you had to fundamentally change to be able to help you to make that transition? Gerard Gousman [00:12:52]: Honestly, coming from for being, very active and constantly out, going out 3, 4 nights a week even when I'm not wasn't working or I wasn't traveling. Still going home and being active in my local art and music event scene. There's no stand abreast. You gotta keep your faces in a place to be active. You're not around. You're not in. Right? So it's coming from making just that desire and having that FOMO was the big thing of man, I'm missing out on a lot of stuff, all those opportunities. And it's it's like the music festivals and concerts and stuff. Gerard Gousman [00:13:26]: It's that high energy. Always go, never knowing exactly what's gonna be next, which some days, that's what it's like around here. And, see, see, making that transition was not as hard as I thought it would be at first using a lot of the things that I learned on the day to day managing the field, the schedules, and having those routines, dealing with wrangling wild and unruly staff and artists. I'm like, it's pretty much what I'm doing here, keeping everything afloat. It's that mode of getting into not having that FOMO and finding what elements of that former life can I bring in? I guess the biggest thing is just that missing out on the activity of being around the my peers. I think that was the hardest part of the disconnect of the transition of not being having that peer relationship. As much as I could, we could go out and take kids to do stuff, but kinda hard to have that feel. Getting over that and finding supplements and finding community and that were more in tune with that part of my lifestyle. Gerard Gousman [00:14:30]: It has been good and just working with the National At Home Dad Network, and I that was a godsend for me, being able to find find the group. And, like, man, there's a whole community of dads out there. It kinda opened me up to me to see, like, yeah. I'm not as isolated in this as I believe I was in the beginning. That's that made things so much easier, designing was really being able to know that I could go out and find the communities if I look for them. And then once I found a couple of places to be able to places to commiserate or places to share what, for me, it would have been a big win. Like, hey. Today today was a no blowout day. Gerard Gousman [00:15:09]: First no blowout day. That's a big deal. My all working, partying event friends were like, no. That's they don't care about them. Like, so finding people that what are my constituted a big win in my current life, finding a community that understood those moments. Dr. Christopher Lewis [00:15:25]: So talk to me about community because you mentioned that you got connected at the national level with the At Home Dad Network and how we've had some past guests from the At Home Debt Network on the show. Talk to me about finding that community, what you had to do to find that community, not only nationally through the work that you're doing on the board of the At Home Dad Network now, but but even locally of being able to find those peers or those other dads that were going through similar things that you could start to have a new community for yourself. What did you have to do to be able to initially find that community and then build, hone, and grow that community for yourself? Gerard Gousman [00:16:04]: Kinda funny. I use some of the things that I would use initially in, like, having events and finding the different event communities and nightlife sectors. They're just going going through and mining through Facebook and different like Facebook and Tumblr and Reddit and looking for those communities and realizing that there are thriving online communities of engaged, active fathers and really putting myself out there and, like, hey, this is what I'm looking for. This is this is what I'm struggling with. These are the problems I'm having. Anybody ever experienced this? And and then finding there's 100 guys like, yeah. Last week, that was me. Exactly that. Gerard Gousman [00:16:42]: Last week. We do that both finding that online community, but finding that those those guys were here in my state, in in my in town and going in, like, alright. Putting myself out there. Hey, you guys. Let's get together. Let's meet. Let's go out and do some media at the park or the toddler gym or we should get out and have a beer or something. And when I took it on myself to really throw myself into it, like, if I don't put myself out there and find it, it's not going it's not just gonna come to and knowing that I was struggling with that disconnect, with that FOMO, just like and having that having that backup. This is something that's not ideas off of with other dads. Once I found myself really being able to throw myself into it and reach out to other dads that I knew, like, a and ask them, like, hey. Are you suffering with the same stuff that I have? And, like, no. No. I'm good. Well, actually, yeah. I didn't wanna say anything, but, yeah, I feel that too in, like, of having friends that, like, man, you know what? Let me check on some of my mom check on my dad friends. And, like, I know how I'm feeling. Let me check up on them. And then once doing that, like, seeing it there like, yeah, a lot of us were having that same thing, but, like, not feeling that we had anybody to talk to. So I might try to invite them into different spaces or just always make make myself available to be a space for my immediate community of dads. Then I've gone on to, like, join my local PTA and try being more active in my kids' school and work with some of the dads there to have more of the fathers on campus and doing doing things and more active in the events. And that has helped. Definitely had comments from other dads in the school. Gerard Gousman [00:18:21]: And it's great to see you always there. Like, I was nervous about going because it's always just the moms, but seeing you in in it and active, like, made me feel okay. Alright? There'll at least be somebody another dad there to talk to. And and every time now I go out, go to pick up the kids, like, hey, man. I see some of the dads, like, hey, we doing this or something. Just checking in on how you doing. Like, not how you doing, but how are you? And checking in on the other day, that's when I see them at pick up and inviting them into the spaces in school and and know, like, hey, it's not a spady thing. They're not gonna load up on you. Gerard Gousman [00:18:48]: Be more active. You got to support. There's other guys here that get it. And we're starting to start to have more of the dads in our school community be more active and stepping up and taking a lead on things. So that's been great to see. Dr. Christopher Lewis [00:19:05]: Yeah. It's so exciting to to hear that you're finding that community. I think that whether you're working or not, it's so important to find a community that you connect with and don't go through fatherhood feeling like you have to do everything by yourself because so many times men step into fatherhood thinking, I've got to know everything. I've got to be that expert. I've got to be the man per se. And you don't you don't have to be the man. You can be a man and know that there are so many other people right around your block or in your apartment complex. No matter where you live that are going through similar things, you just have to reach out and you have to talk to them and just kinda, Gerard, like you said, just say, how are you and truly be willing to ask the question and see and understand and connect on that deeper level. Dr. Christopher Lewis [00:19:59]: So, Gerard, one of the things that I guess that I would ask is now you've got kids at different ages. They're involved in so many different things. The personalities are probably very different from one another. How do you keep that connection and build those unique relationships with each of your kids? Gerard Gousman [00:20:17]: That part definitely difficult, especially once the teenage years and they grow and get their independence, and they construct their own communities. I think I always tap in and let them know I relate to what's going on. I try to I'll let them know, like, I'm always available to talk. Especially for the older kids, like, we don't talk as much and maybe a like my 16 year old. Gerard Gousman [00:20:42]: Are you good? I'm cool. Alright. Tell me about your day. What's we gonna tell me about your week. Alright. Anything new? No. And I'm like, alright. So I'll check-in next month. They're going through and make it a point of having to go on to the, like, all the the school forums and following the the different school Facebook groups and different stuff. Like, I'm like, you got a key from the mayor? Why didn't you tell anybody? Like, it wasn't a big deal. What? The mayor came to send me a school and no. You didn't you didn't wanna tell anybody that that was happening. Like, that isn't a big deal. Well, at least put on a nice shirt that day. So things like that. Like, wanting to be open when I can. I know, not the hippest. They're definitely difficult across but they're totally different generations, I guess. If you ask them, they're totally different generations. What worked with the oldest, I mean, I know I could even work with the 16 year old and between the 16 and the 17 year old. Gerard Gousman [00:21:36]: The way I could communicate and relate with 1 to a totally different approach to the other. And so I'm going through and finding those personality points and being able to figure out, adjust, and tweak my parenting style for each of them. Just realizing that, alright, the way I can talk to one isn't the same as other. Like, one, I can go through and ask something, and they'll just ramble on and tell you all the detail. Another one, it puts pulling teeth. You're asking it's 50 questions. It's 50 questions together. How was your day? Just to get to that point. Gerard Gousman [00:22:08]: And so finding a way that it each communicates and how to research. I wanna watch videos and read articles and Internet snooping and going on to TikTok and Instagram and going through the trends, like, alright. What did I hear them mention? They're in, like, alright. And just trying to stay abreast of what's what's hip in their different areas. Like, alright. What's hip for the in this age group? What's hip in this age group? And how just using those little points I can to as a point of relation to open them up because I may ask a bunch of questions, but then I may mention something about this one artist. And that may be the thing that unlocks that that window that was shut in with blinds and locked and curtains across it. Now our sun's coming right on in now. Gerard Gousman [00:22:54]: It's like, oh, yeah. Gerard Gousman [00:22:55]: That's my favorite song. I was thinking about that. You know what? I was talking to my friends today. You know, we were thinking about going to Greece. I'm like, oh, I Gerard Gousman [00:23:01]: asked you, had you heard this song? All the information I've been trying to get out of you for a month has just come down because I asked you, had you heard this new song? So I'm interested in finding things like that, those little points of connection where I can. And I keep a little Google Keep note list of the things like favorite food and drink orders, and stuff like that. They mentioned this artist one time. Make sure I remember on that. And just jotting down little things for each kid that those bigger points of relation that I can come back to when that normal communication isn't working. Dr. Christopher Lewis [00:23:33]: So this whole story of what we've been talking about was recently put out in front of the world through a New York Times article. And talk to me about that, and why you chose to be a part of that article, why you wanted your story out there, but also what has come from that story being shared? And what are you hearing not only from people around you, but people broader than in your local community. Gerard Gousman [00:24:02]: Yeah. So, so that was a great opportunity. I was definitely happy to be included. The writer, Kelly Coyne, reached out to me, and we had a great discussion about some of the some of this about my experiences as Gerard Gousman [00:24:15]: a father and just in the changing styles of fatherhood, and wanted to work with the org with that Home Dad Network. That's been one of our mission. Being able to help update that face of parenthood and kinda change the popular conception of at home dads. I wanted to have them be included because it's been an interesting journey for me and having more dads be open about the experience. And we we do we have a lot of that. I definitely have gotten that mister mom comment from strangers and friends alike as both an insult and as a compliment from it being termed as something endearing and something as a joke. And knowing that we'd be able to put to face a fatherhood that can be active in being at home and regularly engage fathers, not just done one way. There's not just one way to do that. Gerard Gousman [00:25:10]: So that's something I wanted to, I guess, give my perspective on, of the way that it works for us versus the way that some other dads mentioned the way that they came to this point of being at home dad and being a primary caregiver. So it was honor to be able to share that perspective. I think having some of the response I've gotten, really great all around, friends, family. But having other guys that I know that were dads reach out, I think that's been the best part of seeing, like, man, that's cool. Like, I really really wish I could do that. Like, I wanna do that, but I don't think I have it in me to be able to teach my kids on the day of having the patience or having a structure and being able to be open with them. It's like, hey. It's it's not all every day is not great. Gerard Gousman [00:25:56]: It's not all wins, but it's all positive. It's all necessary. Like, I am always happy at the end result. Right? And once I you have to have those points hitting those walls and having the end result, like, at the end of day, like, well, it's more worse circumstances we could be in and being happy that I am able to have the opportunity. Having the privilege to be able to be in a position that I can be here and make these mistakes and learn with my family and help my family grow. I guess, I haven't had it's negative. I did have, but I reached out for an interview, and it was kinda the the other side of it, they want it, bro. What's the negative response you've gotten? Like, there hasn't isn't any. Gerard Gousman [00:26:35]: Like, what was the bad part? It's not. It's been great as far as the experience. Of course, there's always small things, family things that happen, but it has been a majorly positive experience because that's what I make it. And it's like if in being able to relate that to other fathers. The experience is gonna be what you make. It's not gonna be easy. It's not gonna be as hard as you think it will be either. It definitely will be the days where you gotta sit in the emergency room after you but you get up early and think you're gonna go to bed early, and it's like next thing, you know, you're up till 3 AM, and you gotta get up at 7 AM the next day. Gerard Gousman [00:27:09]: It's like but you keep going, and you find the time to make your peace. And that's the biggest thing that has made this a positive and more eased experience for me, is the focus that my wife and I put on having our home be a place of peace. And I instillment with the kids. Like, I yell just like most dads, I'm sure, yell. Then circling back on that, circling back. Alright. Oh, bring that back. That's why I yelled. Gerard Gousman [00:27:38]: We need to stop yelling as a collective and learning how to quiet yell. This is something I've been working on with the baby, this quiet yelling with him. Like, you can be you can be mad. You can scream, but don't scream at me. I am so angry right now. Don't do that. Like, see? It still works. He reads the facial. Gerard Gousman [00:27:58]: I'm like, he can read the facial expressions. Okay. Okay. Gerard Gousman [00:28:02]: And so sometimes that he's gonna Gerard Gousman [00:28:04]: go into it, and I'm learning, seeing that he is learning that as well, He's screaming, and then he was I'm like, you're getting it. Okay? So I think I'm a you know, things of being able to share the learnings with so much the with the broader community of dads and parents. But just having that small community of dads that I've been friends with forever coming to me and be like, you know what? I've been struggling. I didn't think I could do this. But, you know, I I read your piece and seen your piece like, man, it's thank you. Thank you for putting on that face for us and know that it is hard and that we can do this. And I think that's been the best response for me was having dads that that I knew come to me and, like, that's it right there. Dr. Christopher Lewis [00:28:48]: Now we always finish our interviews with what I like to call our fatherhood 5 where I ask you 5 more questions to delve deeper into you as a dad. Are you ready? Okay. In one word, what is fatherhood? Gerard Gousman [00:28:57]: Yes. What indeed? It's it is a constant what. Amazing. Dr. Christopher Lewis [00:29:03]: When was the time that you finally felt like you succeeded at being a father? Gerard Gousman [00:29:07]: Sometime between 3 and 3:15. Last week, I figured a point to kinda catalog my wins so that on those bad days, those those days I'll take the l, I can draw back to them. So I had one last week. I took my 7 year old and one of his friends, one of his classmates. They were on spring break last week. Took him took him to trampoline par, and it's how seeing how happy they were and having the friend comment like, gee, I always knew you were the coolest dad at school. Gerard Gousman [00:29:36]: And I was like, you remember to tell all the other kids that when you go back to school next week. Okay? He's like, oh, they already know. Like, you alright. Now you're just messing with me. Get out of here. I'm like, what do you want? Gerard Gousman [00:29:46]: He's like, no. Really? We like you. It's like, okay. Maximus is that's my son. Like, Maximus is always he sure ain't always happy, and he seems to have a lot of fun. And you guys do cool things, and you always do cool stuff for us at school. So that's why, like, yeah. You're definitely the coolest dad at school. Gerard Gousman [00:30:03]: And I was like, alright. Gerard Gousman [00:30:04]: I'm gonna remember this. See how long this last. I'm gonna remember this. Bring this back up in a couple of months when you're making fun of me. Because last year in kindergarten, they were all making fun of me for being bald. So to know that I'm one of them thinks that I'm cool. That's not mine. That that I'm taking that weed. Gerard Gousman [00:30:20]: Yeah. Just knowing that it was cool like that. It seemed that not just because we do and giving them stuff, but it's like that. The other kids notice how happy my kids are and think that it's because of me. That that was a win for me. Dr. Christopher Lewis [00:30:32]: Now if I was to talk to your kids, how would they describe you as a dad? Gerard Gousman [00:30:36]: Which one on which day? Open? Fun? Tired? A good cook? Positive. More often than not, I am positive and try to keep them focused on a positive trajectory. Dr. Christopher Lewis [00:30:48]: Who inspires you to be a better dad? Gerard Gousman [00:30:50]: First off, my kids. They I feel like seeing the growth and seeing the smaller lessons. The things that I don't think that they all the things that you don't think they listened to that they didn't hear. And seeing them engage in the world as positivity and seeing them being kind and open and taking care of others, that generally is recharging to me. Like, alright. I'm doing something. I'm doing something right. How can I build on this? Right? So I have kinda curated a great great base of dads. Gerard Gousman [00:31:22]: So I'm getting lots of great dad content from different podcasts. The things that a lot of the dads in our network do, the way they interact with their kids, the risk that dads take, putting their selves out there to not only tackle their home and family stuff, but in going out and living their dreams. And guys like Matt Strain, who all the stuff for his family, but also as a triathlete and doing things like that. Like, man, I couldn't imagine running on a walker like myself. He's like, no, man. It's you just gotta get into it and and go and delve in and do it. Like, having dads who push the envelope and really put their stuff out there to be more than just dad. And try to remember that, a, we were once young, vibrant men with dreams and hopes and hobbies and try the the dads who find themselves and get back to that and are but are still fully active in in their debt. Dr. Christopher Lewis [00:32:19]: Now you've given a lot of piece of advice today, things for all of us to think about and to consider for our own journeys as dads. As we leave today, as we finish up today, what's one piece of advice you'd wanna give to every dad? Gerard Gousman [00:32:32]: I'd say, in closing, the it tends to know that becoming a father doesn't have to mark the end of you being a man. You can find those avenues to be able to go out and maintain your happiness, maintain your peace, and be a person. Right? And don't lose yourself in that, that go to your kids to see that you are not just that, but that you are still vibrant and that you love your life and are living a life that makes you happy, not just living a life of service. So I think that would be the that's the biggest thing I would share is, like, to go out and make sure that your kids see you being happy with your life. Dr. Christopher Lewis [00:33:17]: Well, Gerard, I just wanna say thank you. Thank you for sharing your own journey today. If people people wanna find out more about you, where should they go? Gerard Gousman [00:33:24]: I am so boring, but join the National At Home Data Network. We are doing membership drive. If they come and join us, Come hang out with us at DadCon in Saint Louis this year. That's in October. And it's the only way you can find me in one of those forums if I'm not somewhere wrangling? Dr. Christopher Lewis [00:33:40]: Well, Gerard, just thank you. Thank you so much for being here, and I wish you all the best. Gerard Gousman [00:33:44]: Thank you very much for having me. Appreciate being on. Will be listening. Dr. Christopher Lewis [00:33:48]: If you've enjoyed today's episode of the dads with daughters podcast, we invite you to check out the fatherhood insider. The fatherhood insider is the essential resource for any dad that wants to be the best dad that he can be. We know that no child comes with an instruction manual and most dads are figuring it out as they go along, and the fatherhood insider is full of resources and information that will up your game on fatherhood. Through our extensive course library, interactive forum, step by step roadmaps, and more, you will engage and learn with experts, but more importantly dads like you. So check it out at fathering together dot org. If you are a father of a daughter and have not yet joined the dads with daughters Facebook community, there's a link in the notes today. Dads with Daughters is a program of fathering together. We look forward to having you back for another great guest next week, all geared to helping you raise strong empowered daughters and be the best dad that you can be. Dr. Christopher Lewis [00:34:47]: We're all in the same boat, And it's full of tiny screaming passengers. We spend the time. We give the lessons. We make the meals. We buy them presents and bring your AK. Because those kids are growing fast. The time goes by just like a dynamite blast. Calling astronauts and firemen, carpenters, and musclemen. Dr. Christopher Lewis [00:35:27]: Get out and be the world to them. Be the best that you can be.

Dr. Shaalan Beg and Dr. Arjun Gupta discuss the rationale behind treatment breaks and assess the pros and cons based on feedback and data from patients with advanced-stage gastrointestinal cancers. TRANSCRIPT Dr. Shaalan Beg: Hello and welcome to the ASCO Daily News Podcast. I'm Dr. Shaalan Beg, an adjunct associate professor at UT Southwestern's Simmons Comprehensive Cancer Center in Dallas and senior advisor for clinical research at the National Cancer Institute. I'll be your guest host for the podcast today.  On today's episode, we'll be discussing treatment holidays in GI cancers. Treatment holidays, also known as drug holidays, are increasingly being discussed in clinical practice and involve voluntarily halting treatment for a duration determined by a health care provider if believed to be beneficial for a patient's well-being. We'll address the rationale behind treatment holidays and explore their potential risks and benefits. Joining me for this discussion is Dr. Arjun Gupta, a GI medical oncologist and health services researcher at the University of Minnesota. Dr. Gupta's research on treatment-related time toxicity has explored the benefits of taking a break from treatment.  Our full disclosures are available in the transcript of this episode.  Arjun, it's great to have you on the podcast today. Dr. Arjun Gupta: Thanks, Shaalan. It's a joy to be here. Dr. Shaalan Beg: Your research at the intersection of oncology, supportive care, and care delivery is extremely interesting and important in today's day and age. And you've done extensive work on the concept of time toxicity in cancer treatment. So as we think about these discussions in the clinic on treatment holidays and we talk about risks and benefits, I was hoping that you could help explain the concept of time toxicity in cancer treatment and what our listeners should remember from this. Dr. Arjun Gupta: Sure. So time toxicity is simply the time commitments that cancer care imposes on people with cancer and their loved ones, and the burden that comes along with these commitments. When we specifically think about time toxicity associated with a particular cancer treatment, such as chemotherapy, it's the time costs of pursuing, receiving, and recovering from cancer treatment. Now, we have to acknowledge that much of cancer care is essential. We need blood tests to monitor organ function, we need chemo to shrink tumors, and we need a caring oncologist to break bad news. But we have to remember that oncology care is delivered in an imperfect world. Appointments that should take 10 minutes can take 5 hours. People can have uncoordinated appointments, so they're coming to the clinic 3, 4, 5 times a week. And this affects, of course, not only the patient themselves but also their informal care partners and the entire network around them. And this cancer care can completely consume people's lives, leaving no time for rest, recovery, or pursuing joyful activities.  We interviewed patients and care partners in some qualitative work, and this was specifically people with advanced-stage gastrointestinal cancers. And we asked them what cancer care was like, and some of the words will shock you. People said things like, “It's like being on a leash.” “My life is like being on an extended COVID lockdown.” “Cancer is a full-time job.” A very experienced oncologist said, “It's like being on call. You may or not get called into the hospital, but you need to always be available.” And so this concept of time toxicity really applies to all people with cancer, but perhaps most so for people with advanced-stage, incurable cancer, when time is limited and when treatment regimens are perhaps not offering massive survival benefits. And in some cases, the time costs of pursuing the treatment can even overtake the very marginal survival benefit offered by the treatment. Dr. Shaalan Beg: This is particularly relevant for gastrointestinal cancers that, even in the world of advanced cancers, are highly burdensome in terms of their symptoms and the concept of being on call, whether you're a patient or a caregiver, and the burden that it has, I think will resonate with a lot of us, that it's always in the back of our mind on what if X, Y or Z were to happen? In the FOCUS4-N trial, a randomized trial from the UK, investigators assessed whether taking a treatment holiday for maintenance therapy for metastatic colorectal cancer would have a detrimental effect on progression free survival, overall survival, tolerability and toxicity. It looks like the study found that these decisions regarding maintenance therapy should be individualized, but there were not major differences in outcome. Can you comment on this and what applications that has for us in the clinic?  Dr. Arjun Gupta: Sure. But before diving into the FOCUS4-N clinical trial, I just wanted to share a story from the clinic yesterday. It happened in my clinic yesterday, but I'm sure it happens to thousands of patients across the world every single day. So it was the first visit for a patient with stage 4 colon cancer, and they had polymetastatic disease with disease in the lungs and the liver, no actionable biomarkers, and so very likely to be incurable. And so we discussed the usual port and palliative care appointments and chemotherapy backbone, and doing this every 2 weeks, and then doing scans after 4 to 6 doses of chemo to see how the cancer has responded. And then the patient looks up and asks that question, “Okay. So when does this end? When are we done? Do I need to do this forever and the rest of my life?” These are just such innocent and hopeful questions, because the truth is, there is no established end date. But I shared this story that right off the bat, people are looking for breaks. They've not even started chemo, they've not experienced physical or financial or time toxicity, but just psychologically, being on chemo long-term or forever is a very, very hard adjustment.  And so it's in this context that we should look at the FOCUS4-N clinical trial, which was a sub- study of a larger umbrella trial investigating whether continuing on maintenance chemo with oral capecitabine versus taking a treatment break from chemo affected the progression-free survival in people with metastatic colorectal cancer who had disease control after 4 to 6 months of upfront chemotherapy. So they randomized approximately 250 people. These people had largely been treated with FOLFOX or FOLFIRI. Most did not receive a biologic, and approximately half had partial response and half had stable disease. And then they did scans on these patients every two months or so. And the primary endpoint was progression free survival. The median PFS was approximately 4 months in the capecitabine arm and 2 months in the no treatment arm. Of course, as expected, side effects were higher in the capecitabine arm. But impressively, the overall survival was not different between these two arms. So what we're seeing here is that after this period of 4 to 6 months of intensive chemo, if we take a chemo break versus we get some oral chemotherapy, it may affect how quickly the cancer grows on scans, but it maybe does not affect how long patients live.  Now, how do these data apply for an individual patient? Now, these are incredibly nuanced and personal decisions and patients can and should choose what aligns best with their values. In some work done by Dr. Mike Brundage and colleagues in Canada, they asked 100 people with advanced cancer to consider hypothetical scenarios where a new treatment did not increase the overall survival, but potentially increased the progression free survival at the cost of some physical and other toxicities. And then they asked patients if and what PFS thresholds they would accept for this treatment. And around half of patients said no matter how big the PFS is, we do not want to accept the treatment because it causes some toxicity if I'm not going to live longer. Around a quarter of patients said that if the drug elongated progression free survival by three to six months, I would take it, because that's valuable to me even if I don't live longer. But surprisingly, 1 in 6 patients said that they would accept a treatment with no PFS benefit and no overall survival benefit, even at the cost of side effects. And there was a spectrum of reasons for these preferences that they maybe had the battle narrative that “I want to be a fighter, and I don't want to have any regrets,” just showing how complex people's attitudes and values can be. So the point is that continuing on maintenance treatment versus not doing it is not wrong. The point is we often don't even have these data to offer treatment breaks to patients so that they can make decisions that align with their goals.  So I think that's the biggest takeaway from the FOCUS4-N trial for me is that we have some hard data now to guide patients [FOCUS4-N Editorial]. Now, strictly speaking, when I'm talking to a patient about these data, doing oral capecitabine in 3-week cycles may not feel like much. It's perhaps a visit every 3 weeks for blood work and for meeting someone from the oncology team. There are no IV drugs given. If one does well, this might literally be one visit every 3 weeks. But we have to consider that things rarely go as smoothly as we plan them to. For someone living 100 miles away and having diarrhea and needing IV fluids, they may require 3 to 4 clinic visits for labs and monitoring.  In the FOCUS4-N trial, 50% of patients on capecitabine had at least one treatment delay, denoting some toxicity. In a different but similar CAIRO3 clinical trial that tested capecitabine and bevacizumab, 10% of patients had to discontinue treatment due to toxicity. And so it's important to remember that what might seem a simple and low burden to us may be very burdensome to patients. In some work that we've done ourselves [published in The Oncologist], even a single simple appointment to a clinic, such as a lab test, often ends up taking patients hours and hours. So I think it's all of this that we have to consider when we present these data to patients.  Dr. Shaalan Beg: You've talked about the FOCUS4-N trial, you mentioned the CAIRO3 study as well. How do you see this playing in the clinic? Somebody may be looking to attend a child's wedding or a notable birthday or a trip with the family, and you have the data from these trials supporting you. What are the patient factors in terms of their disease factors, patient factors that you think of when you recommend such a treatment break to a patient? Or, let me flip that over. Who would be a patient that you would be uncomfortable offering a treatment break for with metastatic colorectal cancer?  Dr. Arjun Gupta: Yes, I think disease characteristics are a crucial consideration when we consider who we're even offering these treatment breaks to. I think, number one, is the overall disease burden, and if there's any critical visceral disease and how that's responded and how much it's responded to the upfront chemotherapy induction. I think patients where we're worried about having several sites of bulky disease, some that have not responded as well, I think we have to be very, very careful considering complete chemotherapy breaks. In the FOCUS4-N trial, in subgroup analysis, patients who had stable disease tended to not benefit as much from the chemotherapy break, perhaps indicating that it's really people whose disease is responding, who are doing well, who don't have as much disease burden, who may be better served by these treatment breaks. Dr. Shaalan Beg: Fantastic. I think that provides very good direction for our listeners on how they can apply the results of these trials in their clinic.  So we've talked about treatment breaks as a way to give people their time back and to reduce time toxicity. What are other treatment strategies that you have seen deployed to reduce the burden of receiving cancer treatments in general? Dr. Arjun Gupta: You specifically asked about treatment strategies, so I'll start with that before moving to more broad interventions. We actually interviewed patients and care partners to ask them this question, and one of the things that they said was having prospective information from their oncology care team just about what my expected burden was going to be. So I think people recognize that they need oncology care and the clinicians are trying to help them and it's a broken system, but just knowing that 1 in 4 days will be spent with health care contact or not, or you will spend two hours arguing on the phone with a payer, for example, preparing and supporting people for these burdens is very important. There are obviously some alternative treatment schedules. Certain chemotherapies can be given less frequently now. So if you look at cetuximab in GI cancers, for example, when the initial trials were done, it was given every week, but now we more and more use it every two weeks. And it might not seem like much, but it can open up an entire week for a patient when they can think that I don't need to go in this week at all. So these are just some minor adjustments that we can make in the clinic.  But patients often highlight things that may perhaps not be in the direct control of the oncologist, but in the direct control of us as an oncology community. And perhaps the most frequently cited suggestion was having more care coordination and navigation services. So patients really requested more flexibility in the site of care: “Can I come closer to home?'' In the timing of their care, ‘'Can I come in at 2:00 PM after I get childcare instead of coming in at 9:00 AM?” They really requested cluster scheduling or having appointments on the same day, if possible, instead of taking up Monday, Tuesday, Wednesday, Thursday, coming in so many times. And all of this could potentially be achieved by having a designated care coordinator, someone working directly with the patient and their care partner. And then some patients also highlighted the benefits of telemedicine and home-based care, where they were able to be home more.  But we have to also recognize that those things are not universally good and often can increase burdens on the patients and care partners. Also, I wanted to highlight some feedback we received from oncology clinicians. We asked a variety of oncology clinicians, including nurses, APPs, physicians, schedulers, and social workers, what they thought were the causes of patients' time burden. You'll be surprised to hear that when they started talking about patients' time burdens, they slowly started to talk about their own time burdens. And they said, ‘‘We really want to help people, but we're just doing prior authorization and spending hours on the electronic medical record. And please fix my own time toxicity, and I will fix the patients' time toxicity,” which I thought was very profound because I think everybody who goes into medicine goes into it for the right reasons, and we end up not providing perfect care, not because of us, but because of the system. I take this as a very, very positive sign and as a hope for change. Dr. Shaalan Beg: What inspired you to focus on this topic and your research?  Dr. Arjun Gupta: So I personally just hate waiting at the doctor's office. But yes, it's also been wise mentors, including you, Shaalan, during residency and fellowship, who always told me to keep my ear to the ground and listen to patients. And in full disclosure, time toxicity, and what we've done with it recently, it's nothing new. It's been around for decades. And I think our research group has just sort of named it and shamed it, and now more and more people are starting to think about it.   But I can point to two specific instances that I think of. One was when I was starting fellowship in 2018, I read a piece by Dr. Karen Daily in the Journal of Clinical Oncology, where she quoted Henry Thoreau and said, “The price of anything is the amount of life, or time, that you exchange for it.” And it really struck a chord with me, entering the oncology discipline and seeing what people with cancer go through.   And then the second instance is, I remember my granddad, who was perhaps the most formative person in my life. We were very, very close. And when I was about to enter medical school, he was undergoing chemotherapy for lymphoma. The image that's imprinted in my head is of him putting ketchup on gulab jamun. And I can see Shaalan salivating. But for the listeners who may not know, gulab jamun is an Indian sweet made out of milk, flour, sugar, ghee, molded into balls, deep fried and then served in sugar syrup. And my granddad could not taste anything. He could not taste gulab jamun. All he could taste was ketchup. And so he would put ketchup on everything. And at his oncologist visits when I would accompany him, they would discuss the good news about the cancer shrinking and there being a response, and he was happy, but he could just not taste his gulab jamuns. And it made me realize very early on that the tumor is not the only target.  Dr. Shaalan Beg: What a wonderful story. I think those are really hard to measure, quantify, and when patients do bring those stories into the clinic, I think you realize that you have a very special connection with those patients as well, and it does help us as clinicians give personalized advice. So thanks for sharing.  Arjun, thanks for sharing your valuable insights with us on the ASCO Daily News Podcast today. Dr. Arjun Gupta: Thanks so much for having me, Shaalan. Dr. Shaalan Beg: And thank you to our listeners for your time today. You'll find links to the studies discussed today in the transcript of the episode. Finally, if you value the insights that you hear on the 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. Arjun Gupta @guptaarjun90   Dr. Gupta's Research on Time Toxicity: ·      The Time Toxicity of Cancer Treatment, JCO ·      Consuming Patients' Days: Time Spent on Ambulatory Appointments by People With Cancer, The Oncologist ·      Evaluating the Time Toxicity of Cancer Treatment in the CCTG CO.17 Trial, JCO OP ·      Patients' considerations of time toxicity when assessing cancer treatments with marginal benefit, The Oncologist ·      Health Care Contact Days Experienced by Decedents With Advanced GI Cancer, JCO OP ·      Health Care Contact Days Among Older Cancer Survivors, JCO OP Dr. Shaalan Beg    @ShaalanBeg   Follow ASCO on social media:    @ASCO on Twitter   ASCO on Facebook   ASCO on LinkedIn     Disclosures:   Dr. Arjun Gupta: Employment (An Immediate Family Member): Genentech/Roche   Dr. Shaalan Beg:    Consulting or Advisory Role: Ispen, Cancer Commons, Foundation Medicine, Genmab/Seagen    Speakers' Bureau: Sirtex    Research Funding (An Immediate Family Member): ImmuneSensor Therapeutics    Research Funding (Institution): Bristol-Myers Squibb, Tolero Pharmaceuticals, Delfi Diagnostics, Merck, Merck Serono, AstraZeneca/MedImmune

Drs. Hope Rugo, Diana Lam, Sheri Shen, and Mitchell Elliot discuss key strategies and emerging technology in early-stage breast cancer survivorship, including mitigating risk through lifestyle modification, surveillance for distant recurrence, and optimization of breast imaging. TRANSCRIPT  Dr. Hope Rugo: Hello, I'm Dr. Hope Rugo, your guest host of the ASCO Daily News Podcast today. I'm a professor of medicine and director of breast oncology and clinical trials education at the University of California San Francisco's Comprehensive Cancer Center. I'm also an associate editor of the ASCO Educational Book.   There are currently about 4 million breast cancer survivors in the United States, according to the American Cancer Society, and this number is expected to rise as more women are being diagnosed at early stages of this disease, thanks to advances in early detection and the delivery of more effective adjuvant and neoadjuvant treatment leading to successful outcomes.  In today's episode, we'll be discussing current and emerging clinical strategies for the survivorship period, focusing on a multidisciplinary approach. Joining me for this discussion are Drs. Mitchell Elliott, Sherry Shen, and Diana Lam, who co-authored, along with others, a recently published article in the 2024 ASCO Educational Book titled, “Enhancing Early-Stage Breast Cancer Survivorship: Evidence-Based Strategies, Surveillance Testing, and Imaging Guidelines.”  They also addressed this topic in an Education Session presented at the recent ASCO Annual Meeting. Dr. Elliott is a drug development fellow and clinician scientist trainee at the Princess Margaret Cancer Center in Toronto, Canada. Dr. Sherry Shen is a breast oncologist and assistant attending at the Memorial Sloan Kettering Cancer Center in New York. Dr. Diana Lam is a breast radiologist and associate professor at the University of Washington Fred Hutchinson Cancer Center in Seattle.  Our full disclosures are available in the transcript of this episode.  It's great to have you all on the podcast today. Thank you for being here. Dr. Mitchell Elliott: Thank you so much.  Dr. Sherry Shen: Thank you.  Dr. Hope Rugo: Let's go into the meat of the article now and try to provide some interesting answers to questions that I think come up for clinicians all the time in practice. Your article points out that addressing the challenges in early-stage breast cancer survivorship requires a comprehensive, patient-centered approach, focusing on mitigating risk through lifestyle modification, surveillance for distant recurrence, and optimization of breast imaging.   Dr. Shen, surveillance can facilitate the early detection of recurrence, but ultimately the goal is to prevent recurrence. Lifestyle modifications are a key component of survivorship care, and there are many interventions in this context. Could you summarize the best approaches for mitigating risk of breast cancer recurrence through lifestyle modification and how we might accomplish that in clinical practice? Dr. Sherry Shen: Absolutely. This is a question that we get asked a lot by our breast cancer patients who are so interested in what changes they can make within their lifestyle to improve their breast cancer outcomes. I always tell them that there are three main things, three main lifestyle factors that can improve their breast cancer outcomes.  Firstly, enough physical activity. So the threshold for physical activity seems to be around 150 minutes of a moderately vigorous level per week. So moderately vigorous means something that gets the heart rate up, like walking quickly on rolling hills, for example. Or patients can do a vigorous level of physical activity for at least 75 minutes per week. Vigorous meaning playing a sport, swimming, for example, running, something that really gets the heart rate up.   The second really important lifestyle modification is limiting alcohol use. Keeping alcohol to less than 4 to 7 drinks per week is particularly important for breast cancer outcomes, especially in women who are postmenopausal and have hormone receptor positive diseases. That's where the strongest connection is seen. Lastly, maintaining a healthy weight. We know that women who gain more than 5% to 10% of their diagnosis body weight have a higher risk of breast cancer recurrence and worse breast cancer outcomes. That, of course, is easier said than done, and it's primarily through dietary modifications.  I always tell women that in terms of specific things in the diet, it's really hard to study at a population level because diets vary so much between patients. But what is really important is consuming a plant-forward whole foods diet that prioritizes nutrients and the quality of the diet. A little bit more specifically, it's important to limit the amount of red and processed meats in the diet, really limit the amount of sugar sweetened beverages, ideally to cut that out of the diet entirely, and to consume an appropriate amount of dietary fiber in the range of 20 to 30 grams per day. Those are more specific things that have been associated with breast cancer outcomes.  Dr. Hope Rugo: This is such helpful, practical information for clinicians and for patients. Thank you.  But let's move on to another area, surveillance testing for distant recurrence, an area of great interest, in fact highlighted in a special session at ASCO 2024. In clinic, we've seen that many cancer survivors expressed surprise at the less intensive approach to surveillance testing for recurrence, with the whole idea that if you detected it earlier, the outcome would be better. But it does raise an important question. What is the optimal strategy for monitoring for recurrence? And importantly, can early detection through surveillance testing impact outcome?   Dr. Elliot, your research has focused on ctDNA surveillance and the evolving role of minimal residual disease, or MRD. Can you comment on the current surveillance guidelines for distant recurrence, and then, how we really define true MRD?  Dr. Mitchell Elliott: Those are excellent questions, and I think leaving that Education Session at ASCO left us with even more questions than answers with the current role of MRD in this setting. I think a lot of this comes from wanting to help patients and trying to identify the patients at highest risk of cancer recurrence, with the goal of intervening with effective targeted therapy to prevent metastatic relapse.  Current international guidelines in the United States done by ASCO and the NCCN, as well as ESMO guidelines in Europe and even our local Canadian guidelines, do not suggest that patients undergo routine screening in asymptomatic individuals, whether it be blood work or routine radiographic imaging, as there were some studies that were done in the late 1990s and early 2000s that didn't actually show benefit and actually maybe favored a little bit of harm in these situations. So these recommendations are based on these initial studies. However, we know that in the last 10, 15 years, even 20 years, that breast cancer and the landscape of breast cancer has changed significantly with the introduction of our typical standard classification of breast cancer, the emergence of HER2 positive breast cancer, and thus triple negative breast cancer, which was not actually routine standard testing at the time of these studies, and also the most effective therapies we have to date, including immunotherapy, HER2 targeted therapy and the advent of antibody drug conjugates. We're at prime time right now to potentially revisit this question, but the question is, do we have the right technology to do so? And this is where the circulating tumor DNA has really emerged as a potential option, given its minimally invasive opportunity with a standard blood test to actually identify tumor specific DNA that is highly predictive of distant metastatic recurrence or patient recurrence in general.   The evolving role – we still have a lot of questions in this setting. There have been a lot of retrospective analyses of cohort studies and clinical trials that have shown that modern fit for purpose MRD based tests actually have a high positive predictive value at identifying patients with imminent risk of breast cancer recurrence. The most important thing in this setting is that there are different fit for purpose tests. The initial ctDNA assays were actually genotyping based assays, which look for the presence of mutations in the blood. But we know that the sensitivity of these assays is quite challenging at the level of ctDNA required to actually diagnose patients with very small amounts of residual disease. So the fit for purpose MRD assays are now emerging on the market. And we have several that are in clinical development, several that are in research development, but the high specificity in the setting is very important, which we're seeing some evolving and emerging technologies in this setting. We really don't have the data about if these interventions, so if we were to effectively deploy these MRD based ctDNA assays prospectively in patients, if they will actually improve patient outcomes, and how do we correct and address lead time bias, which might potentially affect study results?  Also, the important thing to think about in this setting is if we are able to find something, we also should have an effective therapy to actually intervene for patients, because the outcome in these trials will actually be dependent not only on identifying early breast cancer occurrence, but also delivering the best targeted intervention for that individual patient, which currently we don't understand fully.   Another really interesting thing is there was a trial, the ZEST trial, as many of our listeners may know, that was randomizing patients with patients with ctDNA detected in the adjuvant setting were randomized through either intervention or standard follow up. And going forward, is it actually an opportunity, or is it possible to actually randomize patients knowing that they have a near 100% likelihood of breast cancer recurrence to observation? So these are several ongoing questions that we have to address as we move forward to deploying this technology in the clinical space.  Dr. Hope Rugo: Really fascinating, and thanks for sharing that. I think really broad and helpful information on these ctDNA [assays] and also our surveillance guidelines, which I think really suggests that you only do surveillance for cause, other than looking for local recurrence and new cancers with breast imaging. So it is really an interesting time where we're seeing evolving technologies and evolving understanding of how we can best do this kind of testing when there are so many different assays out there. I think it's going to take a little while. And also understanding, as you pointed out, trying to target treatments when patients have emerging ctDNA to mutations. And we just have no idea yet if we're going to ultimately change outcomes. This is really helpful, and I think we'll give people a good understanding of where to think about this right now, what to look for in the future.  Now, of course, it's a nice segue into the idea of breast imaging for early breast cancer survivors because that's where we do have data. Dr. Lam, let's talk about how we optimize breast imaging in early-stage breast cancer survivors, because there's such a wide variation in breast cancer imaging survival protocols between different centers and different countries. And of course, here our group is representing two countries and really a broad geographic area. So some of the variations are when to do imaging in terms of frequency, when to start imaging and what kind of examination to do, screening versus diagnostic, MRI versus mammogram. And of course, there are some emerging imaging techniques as well. Could you tell us a little bit about the variation in imaging surveillance protocols in survivors, and the challenges and what you recommend?  Dr. Diana Lam: First off, I want to say that surveillance mammography saves lives and annual intervals are uniformly recommended among both national and international guidelines. However, we know that in practice there are variations in imaging surveillance protocols, with approximately 40% of sites performing imaging at more frequent or six-month intervals for at least one to two years. In addition, there's variation in what type of mammogram someone gets in terms of the indication. They might be getting initial diagnostic mammograms for a short period of time or screening mammograms. However, overall, there is limited evidence in improved outcomes in women getting a diagnostic versus a screening exam for asymptomatic surveillance. In addition, there is limited evidence in increased frequency of surveillance, for example, every six months versus one year.  The real difference between a screen and a diagnostic mammogram, if someone is asymptomatic in the surveillance population, primarily has to do with workflow. For screening examinations, the imaging is generally viewed after a patient leaves the facility, and it might actually take days, maybe even weeks, for the results to be delivered to the patient. In addition, if more imaging is needed, the patient will need to return back to the facility, which does diagnostic imaging work for us to work up this finding. And this practice approach causes diagnostic delays in care. It also disproportionately affects Black and Hispanic women. For diagnostic mammography surveillance, there's generally real time interpretation with immediate results. However, there are both access and scheduling limitations, as not all facilities actually perform these types of examinations. There may also be out of pocket costs which are increased due to the diagnostic indication of this exam.  So  what we found, which is an approach that can aid in minimizing patient costs and decreasing these health disparities, is to provide immediate interpretations of these screening mammography surveillance exams, or so-called online screens where diagnostic workup and potential biopsy can be performed on the same day. Dr. Hope Rugo: This is all very interesting, but what do we tell our patients? How do we, as oncologists, decide on how frequently to get mammograms? Should we be getting diagnostic or screening? And do we sequence MRI with mammograms for everybody or just for certain patients? And then some patients will say, “Well, my doctor does an ultrasound to mammogram.” We don't do that for screening. When do you recommend that? Dr. Diana Lam: We do know that compared to people without a personal history of breast cancer, surveillance mammography is actually less sensitive. It's only about 70% versus 87% or so percent sensitive with over four times more interval cancers or cancers diagnosed after a negative surveillance mammogram compared to the general screening population without a personal history of breast cancer. In addition, about 35% of invasive second breast cancers are actually interval cancers or those not detected by surveillance mammography. However, there is currently no guideline consensus on supplemental breast imaging or additional imaging beyond surveillance mammography. Contrast-enhanced breast MRI is most often recommended, particularly for patients who are already at high risk for breast cancer, such as those with genetic mutations, or patients who have had primary breast cancer diagnosed at a younger age to less than 50 years old, or those patients who have dense breast tissue on mammography.  There is a question about whole breast ultrasound and this is generally not specified or recommended unless the patient is unable to undergo breast MRI. This is primarily due to the number of false positive examinations or findings that are seen that do not amount to breast cancer. We do have the opportunity here to tailor surveillance imaging by selecting people who are at high risk for interval second breast cancers in order to decrease harms and improve patient outcomes. We know that there are a number of factors such as primary breast cancer subtype which affects second breast cancer risk. We know that women who have ER negative and/or hormonal negative breast cancers have significantly higher recurrence rates within the five years of treatment with no significant difference after that 5 years. We also know that there are certain factors such as imaging factors where patients are more likely to develop an interval second cancer with mammography surveillance only. And these are factors such as if their primary breast cancer was hormone negative, if they had an interval presentation to start, or if they had breast conservation without radiation therapy. So, in terms of the future of local breast imaging surveillance, this can be improved with upfront risk prediction and stratification based on the patient, primary breast cancer and treatment factors, as well as looking at imaging test performance to optimally guide the modality and frequency of surveillance imaging.  Dr. Hope Rugo: Really interesting.   Well, thank you all three of you for sharing your valuable insights. This has been so interesting and a great addition to the ASCO Daily News Podcast. I would encourage everyone to actually read the article as well because there's some really great tables and interesting information there that of course we don't have time to cover, but thank you, all three of you.  Dr. Diana Lam: Thank you. Dr. Mitchell Elliott: Thank you for having us. Dr. Hope Rugo: And thank you to our listeners for joining us today. You'll find a link to the article that you can read and look at and cut out the tables discussed today in the transcript of this episode. I encourage all of our listeners also to check out the 2024 ASCO Educational Book where there is an incredible wealth of useful information. Finally, if you value the insights that you've heard today and here on ASCO Daily News Podcast, please take a moment to rate, review and subscribe wherever you get your podcasts. Thanks again.   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 opinion 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. Hope Rugo   @hoperugo   @MitchElliott18 Dr. Sherry Shen @SherryShenMD    Follow ASCO on social media:       @ASCO on Twitter     ASCO on Facebook     ASCO on LinkedIn        Disclosures:      Dr. Hope Rugo:    Honoraria: Mylan/Viatris, Chugai Pharma Consulting or Advisory Role: Napo Pharmaceuticals, Puma Biotechnology, Sanofi Research Funding (Inst.): OBI Pharma, Pfizer, Novartis, Lilly, Merck, Daiichi Sankyo, AstraZeneca, Gilead Sciences, Hoffmann-LaRoche AG/Genentech, Inc., Stemline Therapeutics, Ambryx   Dr. Diana Lam: No relationships to disclose   Dr. Sherry Shen: Honoraria: MJH Life Sciences Research Funding (Inst.): Merck, Sermonix Pharmaceuticals   Dr. Mitchell Elliott:  No relationships to disclose

Dr. Nathan Pennell and Dr. Christopher Booth discuss Common Sense Oncology, a global initiative that aims to advance patient-centered, equitable care and improve access to treatments that provide meaningful outcomes. TRANSCRIPT Dr. Nate Pennell: Hello. I'm Dr. Nate Pennell, your guest host today for the ASCO Daily News Podcast. I'm the co-director of the Cleveland Clinic Lung Cancer Program and vice chair of clinical research at the Taussig Cancer Center, and I also serve as the editor-in-chief of the ASCO Educational Book. My guest today is Dr. Christopher Booth, a professor of oncology and health sciences at Queen's University in Kingston, Ontario, where he also serves as the director of the Division of Cancer Care and Epidemiology. He joins me today to discuss his recently published article in the 2024 ASCO Educational Book titled, “Common Sense Oncology: Equity, Value, and Outcomes that Matter.” Dr. Booth also addressed this topic during a joint ASCO/European Cancer Organization session at the 2024 ASCO Annual Meeting.   Dr. Booth, welcome. Thanks for joining me. Dr. Christopher Booth: Thanks for inviting me here, and I look forward to our conversation. Dr. Nate Pennell: In your article in the Educational Book, and again, thank you so much to you and your co-authors for writing that for us, and during your presentation at the ASCO Annual Meeting, I think your topic really resonated with a lot of people. You explained that the essence of oncology is delivering compassionate care, and I really was struck by the statement, “the treatments need to provide meaningful care, meaningful improvements in outcomes that matter regardless of where the patients live.” Can you just tell us what exactly is Common Sense Oncology? What's your vision for what it can do to help address some of our growing challenges today?  Dr. Christopher Booth: Thanks, Nate. So, the Common Sense Oncology initiative was launched just over a year ago, and it really was a grassroots gathering of clinicians, policymakers, academics, as well as patients and patient advocates who recognize that there's many things we do well in the current cancer care system, but there's also areas that we can improve. And so it was created as a space for us to advocate for greater access for the things that we know really help people, but also to create a space where we can be willing to have some tough conversations and some humility and look within our field at some of the things that maybe aren't working as well as they should, and try to be constructive and not just be critics of the system, but actually be solution-focused and to try to move things forward. The Common Sense Oncology initiative, which has really taken off over the last year, really brings together people from all health systems who care deeply about people and their families who are with cancer. And our mission is that cancer care systems deliver treatments that have outcomes that matter to patients. And the vision is that, as you stated in your introduction, regardless of where someone lives, they have access to those cancer treatments which really do make a difference in their lives.  Dr. Nate Pennell: That certainly sounds like something everyone should be behind. Before we talk about some of what Common Sense Oncology may be doing to help address some of the inequities in cancer care, one of the challenges that is addressed in your paper is the focus on modern clinical trials and perhaps some of the mistakes that we're making in how they are designed. In many ways, we sort of live in a golden age of clinical trials with biomarker driven treatments, which can be incredibly effective in small populations of people, sometimes at great expense. So, focusing on our modern clinical trials, some of the criticisms that have arisen are that perhaps the endpoints that are being designed really aren't ones that are meaningful for patients, or that the gains that they're trying to look for in these trials may not be particularly meaningful. So, talk a little bit about that, if you might.  Dr. Christopher Booth One day, I might write a book called Paradoxes in Cancer Care. But there's a number of these things I think about. I'll start, Nate, in response to your question by talking about something I think of called the ‘three buckets paradox.' The three buckets paradox, I think, reflects a communication failure on the part of our field whereby if a patient or member of the public only reads the newspapers about cancer, they might wonder why we even have cancer hospitals and why Dr. Pennell and Dr. Booth even have a job, because everything we're doing is curing cancer. But we know the reality is different. And so, I conceptualize cancer treatments as going into three different buckets. We have the red bucket, which are those treatments, which really are transformational, and I've been working in oncology for 20 years now and we've seen a number of these treatments. They markedly increase cure rates or help people live for many, many months or extra years of life. And we have those treatments; they're almost out of a science fiction movie. The green bucket is a series of treatments. They're not perhaps transformational, but they're very, very good. They offer substantial benefits to our patients, and we have quite a few of those.  The concern that I think many of us recognize, and just to state emphatically that the problems that CSO is thinking about are not new problems; I think every oncologist has struggled with these things throughout each of our own careers. The concern is the third bucket, which includes many of our newer treatments, some of which, of course, are transformational. But many of the new treatments fall into this bucket, which have important side effects. They have major financial toxicity for patients' families and the system. They have time toxicity, especially in the last year of life. And the reality is most of these new treatments, either there's no proven benefit they help people live longer or better lives, or if they do, it's measured in a number of weeks. I think we need to reconcile the fact that we need to maybe speak honestly about some of the challenges in our field to recognize there's probably too many treatments going into that last bucket, and we need to push harder in the research ecosystem and the policy space to ensure we have more treatments in the first two buckets and that they remain widely available to everyone.  So, to get to the specific issues you raised in your question, Nate, some of the effect sizes and the endpoints we're choosing are problematic, I think. We have many, many examples of incredible clinical trials and new treatments that really make a difference for the lives of our patients. I want to state emphatically that the RCT remains the best tool we have to identify new treatments for patients of tomorrow, and any challenges with clinical trials, actually, it's not the fault of the RCT; these are self-inflicted by us who design, interpret, and act on clinical trials. And so the use of surrogate endpoints is a major issue in our field. And I just want to also state emphatically that there are circumstances where surrogate endpoints make a lot of sense and we should be using them. The problem is, I think with our excitement to get treatment answers more quickly, we've really embraced surrogate endpoints in a very, very rapid way. And in fact, I shouldn't even refer to them as surrogate endpoints. Maybe we should use the term alternative endpoints because in many cases they have been found to not be valid surrogates for those things which we know matter to patients: overall survival and quality of life. So certainly, there's a place for surrogate endpoints. I think we live in an era now where the majority of clinical trials are being designed to detect improvements in progression-free survival rather than overall survival. So historically, most clinical trials were being launched to see if we could help people live longer or feel better.  Now, the default endpoint is progression-free survival, which largely is based on tumor measurements on a CAT scan. And certainly, there are circumstances where those tumor measurements do relate to how someone feels or how long they live, but in most circumstances, that's not the case. I think we need to take a step back and just see the big picture here about where it is that we're going, and how can we raise the bar and ensure that we're identifying treatments that really offer meaningful gains to patients. Because we have to be honest about the fact that the patients and families are the ones who need to live through the side effects, the time toxicity and financial toxicity of these treatments. So, this is about maybe raising the bar and aiming a bit higher than we currently are.  Dr. Nate Pennell: And it looks like CSO basically is putting together teams around evidence generation, evidence interpretation and evidence communication that I guess, is trying to advocate and influence this? Dr. Christopher Booth: Yeah. So, when we launched this initiative, which now is this large global coalition of people, we wanted it to be really solution focused. So, our workstream is oriented around trying to improve how we generate evidence, how we interpret evidence, and how we communicate evidence. So, the evidence generation workstream is being led by a series of leading clinical trialists from all over the world, together with patients and patient advocates who are looking at how we can come up with a framework and principles to design, perhaps a more thoughtful approach to the design, reporting, and conduct of clinical trials. So that's kind of a clinical trials workstream. And I should mention all of these project teams are populated by clinicians, academics, members of the public, as well as patient and patient advocates who, in some cases, are co-leaders of the workstreams.  The evidence interpretation workstream is an educational bucket being led by clinicians and educators, together with patients, to see how we can improve the skill set of the next generation of oncologists to be better equipped in skills and epidemiology, critical appraisal, and critical thinking, so we can better dissect trials which have been well designed from those which might have some limitations, identify those treatments which have very substantial gains from those which are perhaps more marginal. And then the third workstream relates to how we communicate evidence. And this is communication broadly, how we talk about these very complex and nuanced issues at the bedside between oncologist and patient. But how we talk more broadly in society, through the media, with public and policy makers, about some of the challenges in cancer care, recognizing, of course, that no one individual, group or person is going to have the answer for what treatments matter for any specific patient. This is going to vary by every patient with their unique values, preferences and goals in life. But we think we can do a better job of talking about these issues and empowering patients to have the information they need so they can make the treatments that match their own goals and wishes.  Dr. Nate Pennell: Oh, thank you. Another thing that I was interested in in your paper, and when we talk about value and whether these endpoints that are being released for drugs that become approved are meaningful to patients, the other aspect of value is, of course, the cost. And we know that basically every new drug that gets approved, just an astronomical cost these days, which doesn't often factor into whether to approve them. It doesn't often factor into a doctor's decision about whether to use them. Can you talk a little bit about this? And is cost of drugs something that CSO is interested in addressing, or is that more of just a part of the equation in determining value of these? Dr. Christopher Booth: No, I think it's a really important point. So the value construct, I'm not an economist, so I think about this as a simple Canadian chemotherapy doctor would, which is the interface of what you get - so the magnitude of benefits, that's the endpoint, and the effect size - relative to the downsides, the cost, the clinical toxicity, time toxicity, and financial toxicity. So historically, I mean, I think, Nate, you and I will remember maybe 10 or 15 years ago when this really came on the scene, all the conversations focused on the denominator, the cost of cancer medicines, which became astronomical over the last 10 or 20 years. And we've learned a few things about that over time, and I'll get to that in a moment in reference to your question. But I think as individual clinicians or investigators, or even people writing guidelines, we don't have a lot of ability to influence the price of cancer medicines, although I think we still need to speak out about these prices, which are largely unjustified. I'll come back to that. But where I think there's growing interest, and we've seen this in the last five years, is the numerator in that value construct, which is the magnitude of benefit, the endpoint, the effect size. And I think that's where we actually have much more ability to influence. We are the doctors who make treatment recommendations, the experts who write guidelines, the investigators who design trials and so I think we need to take a bit more ownership when it comes to this magnitude of benefit construct. And that's where a lot of the work that Common Sense Oncology is doing rests.  But to answer your question about cost, this is a major problem. We've known that it's been shown by several groups that the price of a cancer medicine is not justified by the R and D cost, that's been shown over time. We also have a problem where the magnitude of benefit offered by that drug also has no bearing to the price. And so this speaks to the need to really, I think, undertake more rigorous health technology assessment and think very carefully about- you know every other economic model that you and I live in, Nate, if, you know, if we have a growing family, we need a larger apartment or house, we spend more money, we get a bigger house. If we want to keep up with our kids on their fast bicycles, we spend more money, we get a better bicycle. And when it comes to cancer medicines, we found that not only is there no relationship between how well the drug works and its price, our group and others have found, if anything, there's an inverse relationship, whereby the drugs with the smallest benefit have the largest price tag. And I don't think you need a PhD in economics to know that is an incredibly broken system. So, I think there's a lot that we need to talk about when it comes to cost. Common Sense Oncology cares deeply about this because it's a huge issue about health justice and global equity and access to cancer medicines. And I think we need to work on that. But we also can't forget about the numerator, which is, to what extent do these treatments help people? Dr. Nate Pennell: I know that every time I see one of these fabulous new presentations at ASCO Plenary or something like that, I just imagine many of the doctors and patients who live outside the U.S., maybe in low- and middle-income countries, who don't have the same access to basic oncology care and specialty oncology care that we do in Western countries, and what goes through their minds when they think about this. And so, I know that this is another big part of what CSO is doing, is thinking about global equity and access to cancer care. And so, can you tell me a little bit about how you're hoping to address that? Dr. Christopher Booth: Yeah. And so, you're right. I guess I'll tell you another Booth cancer paradox. I call this the cancer medicine paradox, which is, on the one hand, in many health systems, I think we'll recognize that there's often overutilization of cancer medicines that are toxic, expensive, and small benefits, especially in the last year of life. So, we have that kind of overutilization paradigm in some parts of the world, but we also have this paradox where we have massive underutilization of those treatments that we know actually have large benefits. And the tragic part of this is many of those treatments are old, generic drugs that actually should be very affordable. Some of this work comes out of myself and a number of my founding colleagues of Common Sense Oncology have a policy role with the World Health Organization Essential Medicine list. My interest in this started, I guess, many years ago when I had a sabbatical in India and lived and worked at a large government cancer hospital for a period of time. And so, from this WHO working group, we launched a project. It's been called the Desert Island study. It was called the Desert Island Project for reasons I'll tell you in a moment. But essentially it was a survey of 1,000 oncologists on the frontlines of care in 82 countries worldwide. And what we are interested in doing is in our role as an advisory group to the WHO Essential Medicine List, we come up with a list of those medicines which are really most important and should be provided in all health systems. And we were interested in going to the frontlines of care, leaving the boardroom of Geneva, and going to the frontlines of care and asking real doctors in the real world, “What medicines do you think are the most important for the patients that you look after?”   So, it was a survey. We asked a lot of demographic questions about their clinical practice and their health system, but we called it the Desert Island Project, because the core question of the survey was based on the thought experiment that you and I have done many times with friends at dinner parties. For example, if you're moving to a desert island and you could only take three books, what would those books be? If you're going to have dinner with any famous podcast host in the world other than Dr. Pennell, who would that person be? And so the thought experiment was, imagine your government has put you in charge of cancer care for your country. You can choose any cancer medicines you want that will be freely available for all cancers and all people in your country. Cost is not an issue, but you can only choose 10. You can only choose 10 of those medicines to take to the desert island to look after all the people in your country, what would those medicines be? And it's amazing; of those thousand oncologists, we found, first of all, remarkable convergence between doctors, regardless of where they work, whether it was a high-income country, middle-income country, lower-income country, the doctors were very pragmatic. When we looked at the drugs that went in that suitcase over and over again, the most common drugs were the good old fashioned cytotoxic chemotherapy drugs and hormone drugs we've been using for 20 or 30 years that we know have very, very large benefits, and in the modern era now should be very affordable because they've been off patent for many years.   In that list of medicines that went to the desert island, there also were some of our newer drugs that are new and they're very expensive. But they are those drugs that have very large benefits. And, of course, all of us would want access to those for our patients. So we found that the doctors are pretty pragmatic about which medicines if they're pushed to offer the largest benefit. But the next part of the question was, okay, you've told us which medicines you want to put in your suitcase to take to the desert island, please now tell us the reality in your health system to what extent can you deliver these medicines? And it was shocking. The vast majority of oncologists, a huge number of them, said they could not even provide doxorubicin or cisplatin without causing major financial toxicity for that patient and family. Even for trastuzumab, now available as a biosimilar, only 15% of oncologists globally said they could provide it universally to all women with breast cancer. Two thirds of oncologists said, “Look, I can give it, but I will catastrophically ruin that patient's family's finances for generations to come.” So, we have a big problem in the sense that we need to focus on those treatments which make a big difference and ensure that they're available to all patients who could benefit, while at the same time raise the bar so that the modern treatments that we're offering also have large benefits.  Dr. Nate Pennell: I think that's really eye opening, and I hope lots of people take away from this, that this is the reality for a huge number, potentially billions of people on the planet that don't have easy access to the same kinds of drugs. We're not even necessarily talking about the expensive drugs with the three-week DFS benefit, but ones that actually could be curing them of their breast cancer and their testicular cancer and their lymphomas, and they can't even get access to those, even though here we might say that they're inexpensive and relatively accessible. So how do we fix that? Maybe this is too big a question for a few minutes in a podcast, but I'm curious to see what CSO is doing to try to help.  Dr. Christopher Booth: Well, the challenges are substantial, and so that's why we've kind of created this group, because it's going to require kind of collective input, I think, of everyone in our field and beyond. And I also think, one of the reasons we've been overwhelmed with interest by the next generation, the young, the trainees, the young oncologists who are very interested in this, and I think they're recognizing that this might be an alternative place for them to put their energy, talent, as they build their own academic careers, is tackling some of these really, really tricky problems where the solutions are not immediately obvious. One thing I think, Nate, that's important is for us to talk about these things and recognize that there's a range of cancer treatments, and that this might help set better expectations for the patients and families when they walk into our cancer centers, let alone in the U.S. and Canada, but also globally. We've seen challenges with all of us as human beings are technophiles, we're drawn towards the new shiny targeted therapy or a robot or treatment in cancer care, and we've seen that play out somewhat tragically. Some of my friends and colleagues in LMICs have told stories where the Minister of Health is about to make a major investment in cancer care, but they want the shiny new monoclonal antibody, because that's perceived as being newer and better, when the reality is that that might add two months of PFS compared to other agents that are much, much- have much larger benefits and, of course, are much more affordable. And there's modeling where even just one of these new medicines, for one cancer, would wipe out the entire cancer medicine budget for that country. Yet we don't have tamoxifen, doxorubicin, cisplatin or even morphine for palliative care available. So, some of this is about socializing these issues, talking about these things that, again, these are not new problems. I think every oncologist worldwide has wrestled with these things, but just at least creating a space where we can talk honestly about this and work towards solutions.  Dr. Nate Pennell: Yeah, I think even just having the framework and the awareness and getting people involved is going to make a big difference. And of course, the people who ultimately are impacted the most by this are the patients with cancer. One of the big aspects in your paper is talking about how patients and patient advocates are central to the CSO movement. So, tell me a little bit about how they became involved and what role they play in CSO. Dr. Christopher Booth: Yeah, so this has been a very intentional and deliberate part of the building of the Common Sense Oncology initiative. So this started with a planning meeting of- a very small planning meeting of 30 people in Kingston, here at Queen's University just over a year ago, with 30 people from 15 different countries, a mix of academics, clinicians, editors, and in that room were five or six patients and patient advocates from day 1, because we wanted to make sure that this is really all about their needs and creating a system that revolves around the outcomes that matter to patients and families. So since then, we've continued to engage broadly. We have a patient priorities project team. There's co-leadership there. One is a colleague and oncologist from New Zealand, but the other co-leader is a patient advocate from- a breast cancer patient advocate from the United States. And all of our project teams have patients and patient advocates as part of their membership. The Patient Priorities Team is working to design a patient charter to guide the design and implementation of clinical trials from the patient's perspective. And as part of that exercise we've been undertaking, we call the CSO speaking and listening tour, where we've had a series of webinars with patient advocacy groups from all over the world, where part of the webinar is us talking about the CSO mission vision, workstream and some of the challenges and solutions we see so that we can provide some education, but also get honest feedback from the front lines to learn kind of where we might be off, what we might be missing, what we should focus on. But then also, the second part of the webinar is about sharing this kind of draft patient charter and getting more broad input from patients and families about what it is they're looking for in a cancer system. And I can tell you that some of the most gratifying correspondence I've had since launching CSO, which has been essentially become my third full time job, is letters from patients and family members of former patients who have since deceased or active patients on treatment, who are saying how much they appreciate this work and how much they feel that oncology can perhaps do a better job talking about some of these things. And they've been giving us some very good ideas and suggestions that, in fact, I'm already incorporating into my clinical practice, because ultimately all of us came into this field to help people with cancer, and I think they can and should and are remaining the center of everything. Dr. Nate Pennell: I think, thankfully, that is a movement throughout medicine, certainly cancer medicine, that patients are becoming more involved much earlier in the process of designing trials. And hopefully that alone will help change the endpoints that we're building into these studies to make them much more meaningful.   So, people are going to read your paper, they're going to get excited, they're going to listen to this podcast, they're going to get even more excited about how they're going to change the world through a little more common sense. So how can they get involved? Is this something that you're open to people working with you? Are there other things people can do to try to help solve some of these frustrating problems?  Dr. Christopher Booth: Yeah, absolutely, Nate. So, we have a website at commonsenseoncology.org. Some of our co-leaders are very active on social media, so they can follow us through social media channels. If you go to our website, there is a membership button where people can join. There's no fee and we won't bombard you with too many emails. But what that has allowed us to do is build this network of people who have diverse interests and skill sets that we can then tap into various projects and workstreams where we could use the help and support. And members have access to things like virtual webinars, journal clubs, critical appraisal sessions, and they get a newsletter from us every two or three months about activities and about ideas and allow exchange of dialogue going back and forth. So certainly, we look forward to growing this initiative, and the challenges are large, but we think that with the collective input of stakeholders from around the world, we could make a difference in moving towards some solutions. Dr. Nate Pennell: And for our listeners, that is commonsenseoncology.org. You can go check this out and join if you are interested in learning more.  Chris, thanks so much for sharing your insights and for all of your work on addressing these complex challenges in cancer care. Dr. Christopher Booth: Thanks, Nate. Grateful for the interview and also for ASCO for giving us the opportunity in the Educational Book and at the Annual Meeting to talk about this work. Dr. Nate Pennell: Thank you. And I also want to thank our listeners for joining us today. You'll find links to the article discussed today, as well as Dr. Booth's presentation at the Annual Meeting, in the transcript of the episode. Finally, if you value the insights that you heard 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. Nathan Pennell @n8pennell Dr. Christopher Booth   Follow ASCO on social media:    @ASCO on Twitter ASCO on Facebook ASCO on LinkedIn   Disclosures: Dr. Nathan Pennell: Consulting or Advisory Role: AstraZeneca, Lilly, Cota Healthcare, Merck, Bristol-Myers Squibb, Genentech, Amgen, G1 Therapeutics, Pfizer, Boehringer Ingelheim, Viosera, Xencor, Mirati Therapeutics, Janssen Oncology, Sanofi/Regeneron Research Funding (Inst): Genentech, AstraZeneca, Merck, Loxo, Altor BioScience, Spectrum Pharmaceuticals, Bristol-Myers Squibb, Jounce Therapeutics, Mirati Therapeutics, Heat Biologics, WindMIL, Sanofi    Dr. Christopher Booth: No relationships to disclose

Dr. Pedro Barata and Dr. Lillian Siu discuss recent advances in cancer vaccines and biomarkers, including the potential of the neoantigen and immune modulatory vaccines and the challenges surrounding cancer vaccine development. TRANSCRIPT Dr. Pedro Barata: Hello, I'm Dr. Pedro Barata, your guest host for the ASCO Daily News Podcast today. I'm a GU medical oncologist at the University Hospitals Seidman Cancer Center in Cleveland, Ohio, and an associate professor of medicine at Case Western Reserve University School of Medicine. I'm also an associate editor of the ASCO Educational Book. And today we'll be discussing a timely article that was recently published in the Educational Book titled, “State-Of-The-Art Advancements on Cancer Vaccines and Biomarkers.”   I'm delighted to welcome one of the article's co-authors and a world-renowned oncologist, Dr. Lillian Siu. She is a senior medical oncologist and director of the Phase 1 Program at the Princess Margaret Cancer Center and a professor of medicine at the University of Toronto.  Welcome, Dr. Siu. Dr. Lillian Siu: Thank you, Dr. Barata; it's great to be here. Dr. Pedro Barata: Wonderful. Dr. Siu will discuss new tools for cancer vaccine development, strategies for combating the immunosuppressive and tumor microenvironment. She will also address cancer vaccine guidelines and patient recruitment strategies to optimize patient selection and access to cancer vaccine trials. I should say that Dr. Siu and her co-authors also addressed this topic during an Education Session at the ASCO 2024 Annual Meeting.  Finally, our full disclosures are available in the transcript of this episode.  So again, Dr. Siu, great to be speaking with you today. I'm looking forward to our discussion.  Dr. Lillian Siu: Thank you, Dr. Barata. And before I begin, I want to acknowledge Dr. Jeffrey Weber and Dr. Inge Marie Svane, who both presented during the ASCO session you mentioned. They gave excellent presentations related to the topic of neoantigen vaccines and immune-modulatory vaccines, which we will talk about later. Dr. Pedro Barata: Wonderful. So let's get started. Cancer vaccines are among the most promising frontiers for breakthrough innovations and new strategies in the fight against cancer. The successes in vaccine development during the COVID-19 pandemic, I think, inspired further research in this area. Why do you think it's important that we harness these recent successes and technological advances to really accelerate progress in vaccine development? Dr. Lillian Siu: Absolutely. I think all of us who have lived through COVID really appreciated how important the COVID vaccine development was to all of us. It saved millions of lives. And I think we witnessed a paradigm change in drug development that none of us thought was possible, that we're able to actually bring a concept to a drug from bench to bedside within an extremely short time. That timeline is not something we would ever imagine to have happened, and it did. And I think it gives us hope that perhaps this is not just limited to the COVID vaccine; it's also extrapolatable to other therapeutics – that we can bring promising medicines to our patients in a really expedited timeline, obviously without compromising their safety.  We now know that cancer vaccines have entered a new, or maybe I should say, renewed era of promise. And it's holding promise on many fronts, Pedro, if I may. It's very exciting in the area of molecular residual disease. In other words, a setting where the cancer is treated definitively by surgery or radiation, plus adjuvant treatment. And we know some patients will relapse because we know they're at high risk. And now we also have different ways to detect these microscopic risks, such as by ctDNA, circulating tumor DNA, or biomarkers. And we know that having some therapeutic that can eradicate these cancers at such microscopic levels would be very attractive, especially with low toxicity, and I think cancer vaccine is such a candidate. And of course, we can even look further into the future of using such treatment in cancer prevention, especially in those with high risk of developing cancer, for example, those with hereditary syndromes like lynch syndrome. We're not there yet, but I think it holds that promise.   So I think, going back to your original question, if we can develop such a therapeutic that is showing promise in a very short period of time, it brings the timeline and the hope to a much shorter timeframe to really deliver to our patients in a very timely manner while safeguarding all the important parts, such as safety and tolerability. Dr. Pedro Barata: Wow, those are such important points. I couldn't agree with you, more. It's really exciting. As I think through this, and as I was reading through your piece, I was thinking it would be great if you could highlight some of the novel approaches to personalized neoantigen vaccine development that are driving progress in this space. Dr. Lillian Siu: Absolutely. And during the session, Dr. Weber spoke about the neoantigen vaccine, and he's a pioneer in this space. So I can only try to iterate some of the points he had delivered during his talk. Neoantigen is a very exciting space for immunologists because we know that tumors express these neoantigens. Many of these are unique antigens that are only expressed in tumors, so-called tumor specific antigens, that we can use as our targets, including vaccines, but not limited to vaccines. And with these altered sequences in DNA in different forms, they could be mutations and splice alterations, etc. We expect that we have modified proteins that are expressed by tumor cells, and these become targets for our drug development of vaccines. And now we can have very specific strategies, very sophisticated algorithms to figure out which neoantigens are more so called immunogenic, more likely to stimulate or activate the immune system, and they can be recognized by T cells. So leveraging this knowledge and technology, we have been able to develop especially mRNA vaccines that are deliverable to our patients through different mechanisms, for example, in lipopeptides, etc., so that we can deliver to the patients in a safe way, such that we can use it to deliver vaccines, such as in the MRD setting that I mentioned earlier, as well as in the advanced disease setting. So Dr. Weber, in his presentation, highlighted one of such vaccines that have been tested in a randomized controlled trial that is KEYNOTE-942, which randomized 157 patients to the mRNA vaccine plus pembrolizumab versus pembrolizumab alone in patients with advanced melanoma. This is a vaccine against 34 mutated neoantigens, and it showed a significant difference in the recurrence free survival with a hazard ratio of 0.56. And if you look at the 18-month relapse free survival rate, it was 78.6% versus 62.2%. Obviously, these are still fairly early data and numbers are still small. I think we would definitely look forward to the randomized phase 3 study of neoantigen vaccine in melanoma and other cancers. Dr. Pedro Barata: No, absolutely. And I agree, it's really exciting. Dr. Weber did a fantastic job going through some of that data. So let me ask you Dr. Siu, as you think about this cancer vaccine field, what are the limitations that you'd highlight when you think about cancer vaccine development? What challenges do you encounter, obstacles do you encounter?  Dr. Lillian Siu: There are many, many potential challenges. And to some extent, that's probably why cancer vaccine development has been somewhat slow for the many decades until more recently. We know first of all; the target has to be recognized. So we need immunogenic targets. So I think a lot of the effort has been put into trying to understand which antigens expressed by cancer cells are immunogenic, able to activate the immune system. They're obviously assay based methods. You're going to try and see if you can ex vivo stimulate immune cells on dishes and models, etc. But we need to also develop in silico computerized algorithms, and now with AI, I think that makes it even more tangible and exciting that we can actually understand through a large number of neoantigens or other antigens, whether we can choose the ones that are most likely going to actually stimulate T cells to be activated. And I think that is one area that there is a lot of interest in development, how to really develop ways to select out the most attractive antigens.   I would also want to highlight that the platforms, which is how we deliver the vaccine, can also pose significant challenges. For example, vaccines can be delivered using peptide-based formulation, cell-based formulation, nucleic acids and viral vectors. For some of these formulations, for example, the peptides very often are restricted to HLA. They can be rapidly degraded in the body, such that they become not really visible to the T cells anymore. Some of the formulations can be very complex. For example, the cell-base; it may need to have cells isolated from patients, cultured, stored and transported to the site of delivery, which can be very complex. For some of the nucleic acid vaccines, they can have very low transfection efficiency. It could be at risk for also having, for example, DNA vaccines integrated into the host genome. And then lastly, there's also the immune suppressive environment in the TME, such that it does not really have the effect when you give it repeatedly. It becomes attenuated and no longer effective. So these are some of the challenges associated with cancer vaccines.  Dr. Pedro Barata: Thank you for that summary. I think it's really important for folks out there, including researchers getting into this field, to be aware of potential obstacles they might encounter.  So let me ask you the opposite question as we see more compelling preclinical and clinical data emerging in this field of vaccine development, what is really exciting you the most about the newest technologies that are shaping the future of cancer vaccines, in your opinion?  Dr. Lillian Siu: I think one I want to highlight is the immune-modulatory vaccine that Dr. Svane, Dr. Inge Marie Svane had presented during the presentation at ASCO. This is a completely different strategy from the neoantigen vaccine. It targets antigens in the tumor microenvironment. And we know that in the tumor microenvironment, we have tumor cells, we have immune cells, and there are many types of cell types, including, for example, macrophages, cancer associated fibroblasts, regulatory T cells, etc. And using these particular cell types, we know that we can really develop vaccines that can stimulate the body's immune system to attenuate, to downgrade some of the negative factors in the tumor microenvironment. And this is what Dr. Svane and her group is trying to do. For example, they have an IDO vaccine that is able to actually target these antigens in the tumor microenvironment, and by that, not just suppressing the negative forces, so to speak, but also activate T cells to help attack cancer cells. I think that's a very interesting area. Very early promise has been seen already in non-small cell lung cancer in early phase trials using the immune-modulatory vaccine.  But going back to your question, what kind of advances; I mentioned earlier about having novel ways to select our antigens that are most immunogenic. There are many algorithms that are being developed, and I think we can try and leverage that kind of knowledge from artificial intelligence, machine learning. So I think that's definitely very exciting. There are also new vaccine platforms coming out. For example, there's recent data using modification of peptides, so called amphiphile vaccines, that already show very early promise in colorectal cancer, microsatellite status, colorectal cancer, as well as in pancreatic cancer in the molecular residual disease setting, where these long peptide vaccines targeting KRAS mutants together with adjuvant oligonucleotide DNA, combined together, can actually be given to patients and reduce the chance of cancer relapse in patients with resected colorectal cancer, as well as pancreatic cancer, with endpoints such as ctDNA or biomarker being downregulated. I think that's a very exciting example. Another very exciting example is cell-based vaccines that are being developed in Europe by the NKI Netherlands Cancer Institute Group, where they are looking at plasmacytoid dendritic cells that are loaded with peptides from different tumor associated antigens and then given to patients, which, again, in non-small cell lung cancer, together with pembrolizumab, has yielded very high response rate. And we will almost certainly see more trials coming out using that particular platform with the dendritic cells. So that's just some of the examples of exciting things that are happening in the vaccine field. Dr. Pedro Barata: Thank you. I'm wondering if you can share with our listeners about what really are the existing guidelines for using these new tools for discovery, methods of treatment, and perhaps optimizing patient selection to access trials.  Dr. Lillian Siu: To be honest, the latest guideline that was published from the FDA that I can find is almost 13 years ago in 2011. So I think it is time for a new guidance, or at least a draft guidance, to give some additional support and guidance in terms of what to do with these new treatments from the FDA and perhaps other regulatory agencies as well. I think we're now entering a very exciting time that cancer vaccines are no longer an ineffective therapeutic. It is now showing evidence of efficacy, not just in the advanced setting, but also in the molecular residual disease setting. There're so many questions to be answered, like how to develop these trials in early disease; what's the end point? Can we incorporate them into the neoadjuvant setting, and if so, how do we give these drugs before surgery, and do we give them maintenance after surgery? I think guidance from the regulatory authorities would be extremely helpful and informative to guide academic groups as well as the pharmaceutical sector to develop these agents in the right way. Dr. Pedro Barata: Dr. Siu, this is a fantastic summary, and we certainly are on the cusp of a new dawn of discovery and development in cancer vaccines, and super interesting to hear from you talking about it. Before letting you go, do you have any final thoughts that you'd like to share with the listeners, with all of us about this topic? Dr. Lillian Siu: I think as a drug developer like you are, I'm extremely excited because we now have yet another way to leverage the host immunity as a cancer therapeutic, and it is going to be opening a new door to combination therapy because we can imagine combining these treatments with other immunotherapeutics such as bispecific molecules such as CAR Ts and even vaccine plus vaccine combination is feasible. That came up actually during the session as a question from the audience. Can we combine neoantigen vaccines and immune-modulatory vaccines together? And both of our speakers who presented felt that it was possible. Obviously, we have to understand the sequence question and the endpoints question, but the fact that it opens a new door to combinatorial therapy, not just with immunotherapeutics, but perhaps with other therapeutics as well, antibody drug conjugates, etc., really, I think, is very exciting for this field to become further explored.  I mentioned earlier in the podcast that the whole area of cancer prevention is something that we have not been tapping into for the last decade with vaccines because it has not been very effective. Viral vaccines, of course, HPV and other vaccines targeting viruses, but targeting cancer cells is not something we have been successful using vaccines to prevent cancer from developing. I think we would be very interested to see if this will become a reality in the next decade. I think we would start off with patients with high risk of developing cancers such as, as I mentioned earlier, those with lynch syndrome, those harboring BRCA alterations, for example. Can we use these vaccines to actually prevent the cancers from developing in such high-risk individuals? I think the field is definitely open to that consideration.  Dr. Pedro Barata: Definitely. And I'd like to thank you, Dr. Siu, for sharing these great insights with us today on the ASCO Daily News Podcast. Dr. Lillian Siu: Thank you so much for your time.  Dr. Pedro Barata: And thank you to all the listeners for your time today. You'll find a link to the article discussed today in the transcript of this episode, and I encourage you to check out the 2024 ASCO Educational Book. Finally, if you value the insights that you hear on the podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. So again, thank you so much for your time and see you soon.   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. Pedro Barata  @PBarataMD  Dr. Lillian Siu  @lillian_siu   Follow ASCO on social media: @ASCO on Twitter ASCO on Facebook ASCO on LinkedIn   Disclosures:    Dr. Pedro Barata: Honoraria: UroToday  Consulting or Advisory Role: Bayer, BMS, Pfizer, EMD Serono, Eisai, Caris Life Sciences, AstraZeneca, Exelixis, AVEO, Dendreon  Speakers' Bureau (Inst): Caris Life Sciences, Bayer, Pfizer/Astellas  Research Funding (Inst.): Blueearth, AVEO, Pfizer, Merck    Dr. Lillian Siu:  Leadership (Immediate family member): Treadwell Therapeutics  Stock and Other Ownership Interests (Immediate family member): Agios   Consulting or Advisory Role: Merck, AstraZeneca/MedImmune, Roche, Voronoi Inc., Oncorus, GSK, Seattle Genetics, Arvinas, Navire, Janpix, Relay Therapeutics, Daiichi Sankyo/UCB Japan, Janssen, Research Funding (Institution): Bristol-Myers Squibb, Genentech/Roche, GlaxoSmithKline, Merck, Novartis, Pfizer, AstraZeneca, Boehringer Ingelheim, Bayer, Amgen, Astellas Pharma, Shattuck Labs, Symphogen, Avid, Mirati Therapeutics, Karyopharm Therapeutics, Amgen

Dr. Neeraj Agarwal and Dr. Rana McKay discuss promising studies in GU cancers featured at the 2024 ASCO Annual Meeting that highlighted improved outcomes in urothelial carcinoma, improved survival in renal cell carcinoma, and the role of ctDNA as a potential biomarker for predicting outcomes.   TRANSCRIPT Dr. Neeraj Agarwal: Hello and welcome to the ASCO Daily News Podcast. I'm Dr. Neeraj Agarwal, your guest host of the ASCO Daily News Podcast today. I am the director of the Genitourinary Oncology Program, a professor of medicine at the University of Utah's Huntsman Cancer Institute, and editor-in-chief of the ASCO Daily News.  I am delighted to welcome Dr. Rana McKay, a GU medical oncologist and associate professor at the University of California San Diego. Today, we'll be discussing some key GU abstracts featured at the 2024 ASCO Annual Meeting. Our full disclosures are available in the transcript of this episode. Rana, we're thrilled to have you on the podcast today to share your insights on key advances in GU oncology from ASCO24. Dr. Rana McKay: Thank you so much, Neeraj; it's a pleasure to be here. Dr. Neeraj Agarwal: So, Rana, let's start with some bladder cancer abstracts. Could you tell us about Abstract 4503, titled “Impact of exposure on outcomes with enfortumab vedotin in patients with locally advanced or metastatic urothelial cancer”? Dr. Rana McKay: Of course, I would be delighted to. First, I would like to remind our listeners that enfortumab vedotin (EV) was approved as a monotherapy for the treatment of locally advanced or metastatic urothelial cancer based on the results of EV-201 and EV-301 trials. In these pivotal studies, EV was initiated at a dose of 1.25 mg/kg, and dose modifications, such as reductions and interruptions, were used to manage adverse events. In the abstract presented at ASCO 2024, Dr. Daniel Petrylak and colleagues conducted a post-hoc exploratory analysis to evaluate the association between EV plasma exposure and outcomes. They used multiple pharmacokinetic samples collected during the first two cycles and pre-dose samples from 3 EV monotherapy studies, namely EV-101, EV-201, and EV-301, that were conducted in patients with previously treated locally advanced or metastatic urothelial carcinoma. Dose reductions to 1 mg/kg were required in 42.1% and 35.1% of patients in the EV-201 and EV-301 trials, respectively, and reductions to 0.75 mg/kg were required in 13.6% and 11.1% in the EV-201 and EV-301 trials, respectively. Higher EV exposure during the first two cycles was associated with a higher objective response rate. The ORR was 21.4% for the dose of 0.75 mg/kg, while it was 18.5% for the dose of 1.0 mg/kg. Interestingly, increasing the dosage to 1.25 mg/kg improved the ORR, which ranged from 40 to 51.1% across various studies. In the EV-301 trial, when comparing the efficacy of EV to chemotherapy, EV improved PFS and OS across all dose quartiles, and there was no evidence that recommended dose modifications impacted long-term efficacy outcomes. Dr. Neeraj Agarwal: Thank you, Rana, for this great summary. I would like to add that the meticulously conducted pharmacokinetic studies demonstrated that serum levels of EV correlated with responses. Importantly, patients who had to decrease the dose did not experience compromised outcomes as EV improved PFS and OS outcomes vs chemotherapy in across all exposure quartiles in the EV-301 trial where EV was compared with chemotherapy. These findings highlight the need to start at the recommended dose of 1.25 mg/kg and reduce it, if necessary, however, clinicians should not start at a lower dose.  Dr. Rana McKay: I totally agree with you, Neeraj. Now, moving on to a different setting in bladder cancer, what can you tell us about LBA4517, titled “Perioperative sacituzumab govitecan alone or in combination with pembrolizumab for patients with muscle-invasive urothelial bladder cancer: SURE-01/02 interim results”? Dr. Neeraj Agarwal: Of course! So, SURE was a multicohort, open-label, phase 2 study in patients with muscle-invasive bladder cancer assessing sacituzumab govitecan as a neoadjuvant therapy either alone in SURE-01 or as a combination with pembrolizumab followed by adjuvant pembro in SURE-02 in a flexible design allowing a bladder-sparing approach. In the abstract presented at ASCO 2024, Dr. Antonio Cigliola and colleagues report interim results of the SURE-01 study. Patients with cT2-4N0M0 urothelial carcinoma who were ineligible for or refused cisplatin-based neoadjuvant chemotherapy were planned to receive 4 cycles of neoadjuvant sacituzumab govitecan at a dose of 10 mg/kg followed by radical cystectomy.  An extensive assessment was performed at baseline and after the 4 cycles for response assessment. Patients with clinical complete response defined with negative MRI, cystoscopy and ctDNA assays refusing radical cystectomy were offered redo transurethral resection of the bladder tumor or repeat TURBT followed by observation in the absence of viable high-grade tumor in the bladder. The primary endpoint was pathological complete response rate, while secondary endpoints included pathological downstaging rate and safety. After the first 8 patients were enrolled, the protocol was amended due to the occurrence of grade 3 and 4 neutropenia and diarrhea in 75% and 50% of patients, respectively, and 2 deaths – one of which was deemed to be treatment-related due to sepsis. Key protocol changes included the reduction of the dose of sacituzumab govitecan to 7.5 mg/kg, the introduction of G-CSF as primary prophylaxis, and the exclusion of patients at high risk of febrile neutropenia per ASCO guidelines.  Among 21 patients who received at least one cycle of sacituzumab govitecan and included in the intention-to-treat population, 47.6% had a complete pathological response, and 52.4% had pathological downstaging. 11 patients underwent radical cystectomy, while 7 received repeat-TURBT due to complete clinical response or patient preference. Regarding the safety profile, grade 3 or more adverse events occurred in 42.5% of patients. Treatment-related adverse events leading to dose interruptions or discontinuations were more common before the protocol amendment. It is noteworthy that 3 patients died after treatment discontinuation, with one deemed treatment-related, as previously mentioned. Dr. Rana McKay: Thank you, Neeraj, for a great summary. The pathological complete responses observed show promising activity for sacituzumab govitecan as a neo-adjuvant therapy and a window for bladder-sparing approaches, which is definitely exciting news for our patients! However, although the 3 deaths encountered in a neo-adjuvant setting could be concerning, the improvement of the safety profile after protocol amendments is reassuring and supports the continuation of the study. Dr. Neeraj Agarwal: Before wrapping up the bladder cancer section, would you like to share your insights with our listeners on Abstract 4518, titled “Quantitative circulating tumor DNA (ctDNA) assessment in patients with advanced urothelial carcinoma treated with pembrolizumab or platinum-based chemotherapy from the phase 3 KEYNOTE-361 trial”?  Dr. Rana McKay: Sure. So, the KEYNOTE-361 trial was a randomized phase 3 study with 3 arms that included pembrolizumab plus chemotherapy, pembrolizumab monotherapy, or chemotherapy alone in patients with previously untreated advanced urothelial carcinoma. The results showed that neither the combination of pembrolizumab plus chemotherapy nor pembrolizumab monotherapy improved survival outcomes compared to the chemotherapy arm. So, in this exploratory analysis presented at ASCO24, Dr. Tom Powles and colleagues sought to assess the role of ctDNA as a potential biomarker between the pembrolizumab monotherapy arm and the chemotherapy arm. Tumor tissue mutations were evaluated using whole exome sequencing, and plasma ctDNA was assessed with the Guardant 360 assay. Changes in ctDNA from pre-treatment cycle 1 to on-treatment cycle 2, so 3 weeks post-baseline assessment, were quantified by the maximum variant allele frequency of tumor tissue-specific mutations.  Results showed that lower baseline ctDNA levels were associated with improved clinical outcomes of response in the pembrolizumab arm but not in the chemotherapy arm. This improvement in the pembrolizumab arm was also robust to adjustment for tumor mutational burden and PD-L1. Additionally, chemotherapy led to a ctDNA clearance rate of 41% compared to 11% in the pembrolizumab arm. Patients who had a large ctDNA reduction with pembrolizumab had significantly improved outcomes compared to those achieving a large reduction with chemotherapy with a hazard ratio of 0.25. However, this did not replicate in patients who did not achieve a large reduction, as these patients had similar outcomes across both arms. Let's switch gears to kidney cancer and start with Abstract 4508, reporting the final OS analysis from the JAVELIN Renal-101 trial. Neeraj, what would you like to tell us about this abstract? Dr. Neeraj Agarwal:  Well, as a quick reminder, the JAVELIN Renal-101 was a randomized phase 3 trial where patients with previously untreated advanced or metastatic clear cell renal cell carcinoma were randomized to receive either the combination of avelumab plus axitinib or sunitinib. In previous analyses, the combination of avelumab and axitinib significantly improved PFS compared to sunitinib and was subsequently approved by the FDA for the first-line treatment of patients with advanced RCC in 2019. This superiority in PFS was maintained across the different analyses; however, OS data remained immature. In the abstract presented at ASCO24 by Dr. Robert Motzer from Memorial Sloan Kettering Cancer Center and colleagues, the authors reported OS results at a median follow-up of around 73 months and a minimum of 68 months for all patients, which is the longest follow-up for any ICI-TKI combination in RCC. The final analysis in the overall population favored the combination of avelumab plus axitinib with a median OS of 44.8 months compared to 38.9 months with sunitinib, however, this did not reach statistical significance with a hazard ratio of 0.88. The PFS results and safety profile were consistent with previous analyses.  Dr. Rana McKay: Thank you, Neeraj, for such a nice overview of this abstract. These new data could make this regimen less optimal than other ICI-TKI combinations in the first-line mRCC setting.   Dr. Neeraj Agarwal: I concur, Rana. Moving on to perhaps one of the most exciting GU abstracts featured, Abstract 4506, titled “Circulating kidney injury molecule-1 biomarker analysis in IMmotion010: A randomized phase 3 study of adjuvant atezolizumab vs placebo in patients with renal cell carcinoma at increased risk of recurrence after resection.” Rana, what are your thoughts on this abstract? Dr. Rana McKay: Well, first, I would like to take a step back and remind our audience that in the IMmotion010 trial, patients with resected intermediate to high-risk RCC with clear cell and/or sarcomatoid component were randomized in a 1:1 ratio to receive either atezolizumab or placebo. Investigator-assessed disease-free survival, which was the primary endpoint, favored the atezolizumab arm but did not reach statistical significance. In the abstract featured at ASCO24, Dr. Laurence Albiges and colleagues build on data previously reported in the ASSURE and CheckMate 914 trials and report provocative findings regarding a molecule known as kidney injury molecule 1 or KIM-1, which is a type 1 membrane glycoprotein that has been identified as a minimally invasive potential peripheral blood circulating biomarker. The KIM-1 level of 86 pg/ml was identified as the optimized threshold for defining post-nephrectomy KIM-1 high vs KIM-1 low subgroups in the IMmotion010 trial. KIM-1 levels were measured at baseline or pre-treatment, at cycle 4 day 1, and at disease recurrence or discontinuation without disease recurrence. Baseline characteristics were balanced between the KIM-1 high and KIM-1 low groups, except perhaps for a slightly higher pathological stage in the KIM-1 high subgroup.  I would like to highlight 3 key takeaways from this abstract. First, KIM-1 high level was associated with significantly worse DFS with a hazard ratio of 1.75. Second, patients in the KIM-1 high subgroup receiving atezolizumab had a 28% reduction in the risk of recurrence or death compared to those receiving placebo, while those in the KIM-1 low subgroup had comparable outcomes across both treatment arms. Third, patients in the KIM-1 high subgroup receiving atezolizumab were significantly less likely to experience an on-treatment increase in KIM-1 levels, which was associated with worse DFS in both high and low KIM-1 subgroups, regardless of treatment arm. Thus, these findings support the use of KIM-1 as both a predictive and prognostic biomarker in patients with RCC. Dr. Neeraj Agarwal: Yes, Rana, this is amazing data! I would like to add that these results warrant larger and, ideally, prospective studies to validate the utility of KIM-1 as a noninvasive biomarker for identifying minimal residual disease after nephrectomy and for predicting outcomes to immune checkpoint inhibitors. Dr. Rana McKay: Also, in the field of biomarkers, 2 abstracts interrogating different biomarkers in a different setting, so in patients with advanced or metastatic RCC were presented. Neeraj, could you tell us more about these abstracts? Dr. Neeraj Agarwal: Of course! I think you are referring to Abstracts 4504 and 4505. In abstract 4504, Dr. Toni Choueiri and colleagues sought to assess the clinical implications of different biomarkers in the CLEAR trial, which was a randomized phase 3 trial that led to the approval of the combination of pembrolizumab plus lenvatinib in the first-line mRCC setting. On the other hand, in abstract 4505, Dr. Brian Rini presented biomarker results in KEYNOTE-426, which was also a randomized phase 3 trial based on which the combination of pembrolizumab plus axitinib was approved in patients with mRCC. The authors in both trials sought to investigate the role of biomarkers in predicting treatment outcomes from 3 different angles. Starting with PD-L1 expression, the superiority of the combination arms over sunitinib was not impacted by PD-L1 status in both trials. Moving on to RCC driver gene mutations on whole exome sequencing, such as VHL, SETD2, PBRM1, and BAP1, ICI combination therapies improved outcomes regardless of mutation gene status, and this improvement was statistically significant with PBRM1 mutations in KEYNOTE-426 compared to wild-type PBRM1, but this did not replicate in the CLEAR trial. Finally, using transcriptomic signatures derived from RCC trials, especially the IMmotion 151 and JAVELIN Renal 101 trials, where 7 clusters or molecular subtypes were identified, the combination arms outperformed sunitinib in all clusters in both trials and the magnitude of this benefit differed across clusters.  Dr. Rana McKay: Thank you for this very interesting summary and comparison of the results of these 2 abstracts. These findings support the use of ICI-based combinations in all patients with mRCC as a first-line option. Although these abstracts could not identify specific biomarkers that could guide us clinicians in treatment selection, they provide very interesting biological insights on these molecular biomarkers that are, however, not yet clinically actionable. Dr. Neeraj Agarwal: Very interesting point, Rana. Moving on to prostate cancer, let's start with abstract LBA5000 titled, “Cabazitaxel with abiraterone versus abiraterone alone randomized trial for extensive disease following docetaxel: The CHAARTED2 trial of the ECOG-ACRIN Cancer Research Group (EA8153).” Rana, what is your takeaway on this abstract? Dr. Rana McKay: As a reminder to our audience, the CHAARTED2 trial was a randomized open-label phase 2 study that compared the combination of cabazitaxel and abiraterone to abiraterone alone in patients with mCRPC previously treated with ADT plus docetaxel in the hormone-sensitive setting. The primary endpoint was progression-free survival. After a median follow-up of 47.3 months, Dr. Christos Kyriakopoulos and colleagues reported in LBA5000 that patients receiving the combination of cabazitaxel plus abiraterone had a 27% reduction in the risk of progression or death. However, there was no significant difference in overall survival between the two arms, with a median OS of 25 months in the cabazitaxel+abiraterone arm and 26.9 months in the abiraterone arm, although the study was underpowered for this endpoint. Regarding the toxicity profile, the combination of cabazitaxel and abiraterone was overall well tolerated with more cytopenias, as expected.  Dr. Neeraj Agarwal: Very nice summary of this abstract, Rana. I would like to add that the treatment landscape of patients with mHSPC has evolved since the design of the study and now includes combination therapies of ADT + ARPI with or without docetaxel, and ADT + docetaxel is no longer a standard of care, which limits the applicability of these results in clinical practice today.  Dr. Rana McKay: Excellent point, Neeraj. Let's discuss Abstract 5001, titled “CYCLONE 2: A phase 3 study of abemaciclib with abiraterone in patients with metastatic castration-resistant prostate cancer”. Dr. Neeraj Agarwal: Sure! In the abstract featured at ASCO24, Dr. Matthew Smith and colleagues report the primary results of the CYCLONE 2 trial, which was a randomized phase 2/3 study that investigated the combination of abemaciclib plus abiraterone versus abiraterone monotherapy in patients with mCRPC. Stratification factors included radiographic progression at study entry, presence of measurable disease, and prior docetaxel for mHSPC. Part 1 of the study established the recommended phase 2 dose of abemaciclib at 200 mg twice daily. In part 2, patients were randomized to placebo or abemaciclib, and an adaptive interim analysis using prespecified criteria was performed and recommended the expansion of the study to part 3. The primary endpoint was investigator-assessed radiographic progression-free survival by RECIST 1.1 and PCWG3 criteria in the intention-to-treat population. At the time of the primary analysis, adding abemaciclib to abiraterone did not improve rPFS, with a hazard ratio of 0.83. The median rPFS was 22 months for the combination arm and 20.3 months for the abiraterone arm. The combination was well tolerated, and the safety profile was consistent with the known adverse events. Dr. Rana McKay: So, the addition of abemaciclib to abiraterone did not improve outcomes in patients with mCRPC. These findings suggest that no further investigation is warranted for abemaciclib or CDK4/6 inhibitors in biomarker-unselected patients with prostate cancer.  Dr. Neeraj Agarwal: Rana, what's your take-home message on Abstract 5006, titled “Health-related quality of life results from PRESTO (AFT-19), a phase 3 randomized trial of intensification of androgen blockade in patients with high-risk biochemically relapsed castration sensitive prostate cancer”? Dr. Rana McKay: So, as a reminder to our audience, the PRESTO trial was a randomized phase 3 study that assessed the effects of intensified androgen receptor blockade in patients with biochemically recurrent prostate cancer following local therapies. Patients with a PSA doubling time of less than 9 months and no evidence of metastatic disease were randomized to receive either 52 weeks of ADT alone, ADT plus apalutamide, or ADT plus apalutamide plus abiraterone. In their paper published earlier this year in the Journal of Clinical Oncology, the authors showed that patients receiving ADT plus apalutamide with or without abiraterone had significantly longer PSA-progression-free survival than those receiving ADT alone. In the oral presentation featured at ASCO24, Dr. Ronald Chen and colleagues report health-related quality of life outcomes that were assessed using various questionnaires or scales at baseline, at cycle 7, which is around 6 months on treatment, and at the end of treatment. Results showed that this intensified approach with apalutamide did not significantly increase severe adverse events, did not lengthen the time to testosterone recovery, and did not meaningfully increase common treatment-related symptoms such as hormonal symptoms, sexual dysfunction, hot flash interference, and fatigue. Importantly, additional intensification with abiraterone did not further improve PSA-PFS but did increase the rate of serious adverse events, lengthened the time to testosterone recovery, and increased hot flash interference.  Dr. Neeraj Agarwal: So, in conclusion, the PRESTO trial supports using intensified androgen blockade with apalutamide to improve PSA-PFS in patients with high-risk biochemically recurrent prostate cancer without compromising health-related quality of life. However, adding abiraterone did not offer additional benefits and increased side effects.  Dr. Rana McKay: Let's move on to LBA5002 titled, “A randomized, double-blind, placebo-controlled trial of metformin in reducing progression among men on expectant management for low-risk prostate cancer: The MAST (Metformin Active Surveillance Trial) study.” Would you like to share your insights on this abstract with our listeners? Dr. Neeraj Agarwal: Absolutely. MAST was a randomized, double-blinded, placebo-controlled trial that investigated the impact of metformin on the progression of low-risk localized prostate cancer in patients choosing to undergo active surveillance. Eligible patients had biopsy-proven, low-risk, localized prostate cancer diagnosed within the past 6 months, characterized by a Gleason score of less than 6 observed in less than one-third of the total cores, less than 50% positivity in any one core, a PSA level of less than 10 ng/ml, and a clinical-stage between T1c and T2a. Patients were randomized in a 1:1 ratio to receive either metformin 850 mg twice daily or placebo for three years. All patients underwent repeat prostate biopsy at 18 and 36 months. The primary endpoint was time to progression, defined as the earliest occurrence of primary prostate cancer therapy, such as prostatectomy, radiation, hormonal therapy, or pathological progression on subsequent biopsies, which was defined as more than 1/3 of total cores involved, at least 50% of any one core involved, or Gleason pattern 4 or higher. The study included 407 patients, with 204 receiving metformin and 203 receiving a placebo. Results presented by Dr. Anthony Joshua showed no statistically significant difference in progression-free survival, including therapeutic and pathologic progression, with an unadjusted hazard ratio of 1.08.  Interestingly, there was a signal that patients with a BMI more than 30 had a detriment to taking metformin with a higher risk of progression compared to those receiving placebo with an unadjusted HR of 2.39 and a p-value of 0.01. Dr. Rana McKay: I would like to add that this study showed that metformin use does not prevent the progression of low-risk localized prostate cancer on active surveillance and could represent a potential detriment for patients with high BMI at study entry. Dr. Neeraj Agarwal: Yes, Rana, I concur. Any final remarks before we conclude today's podcast? Dr. Rana McKay:  Thank you, Neeraj; it's been wonderful being here with you today and you having me on the podcast to highlight these important advances and the amazing work that many investigators are conducting and the patients who were involved in the context of these trials. It's really excellent to see these updated results.   Dr. Neeraj Agarwal: Before we wrap up this podcast, I would like to say that we have reviewed a selection of abstracts addressing prostate, bladder, and kidney cancer, which are significantly impacting our medical practices now and in the near future. Rana, thank you for sharing your insights today. These updates are undoubtedly exciting for the entire GU oncology community, and we greatly appreciate your valuable contribution to the discussion. Many thanks. And thank you to our listeners for joining us today. You will find links to the abstracts discussed today on the transcript of this episode. 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.   Find out more about today's speakers:    Dr. Neeraj Agarwal   @neerajaiims   Dr. Rana McKay  @DrRanaMcKay     Follow ASCO on social media:      @ASCO on Twitter      ASCO on Facebook      ASCO on LinkedIn         Disclosures:        Dr. Neeraj Agarwal:         Consulting or Advisory Role: Pfizer, Bristol-Myers Squibb, AstraZeneca, Nektar, Lilly, Bayer, Pharmacyclics, Foundation Medicine, Astellas Pharma, Lilly, Exelixis, AstraZeneca, Pfizer, Merck, Novartis, Eisai, Seattle Genetics, EMD Serono, Janssen Oncology, AVEO, Calithera Biosciences, MEI Pharma, Genentech, Astellas Pharma, Foundation Medicine, and Gilead Sciences     Research Funding (Institution): Bayer, Bristol-Myers Squibb, Takeda, Pfizer, Exelixis, Amgen, AstraZeneca, Calithera Biosciences, Celldex, Eisai, Genentech, Immunomedics, Janssen, Merck, Lilly, Nektar, ORIC Pharmaceuticals, Crispr Therapeutics, Arvinas      Dr. Rana McKay:   Consulting or Advisory Role: Janssen, Novartis, Tempus, Exelxis, Pfizer, Bristol-Myers Squibb, Astellas Medivation, Dendreon, Bayer, Sanofi, Merck, Vividion, Calithera, AstraZeneca, Myovant, Caris Life Sciences, Sorrento Therapeutics, AVEO, Seattle Genetics, Telix, Eli Lilly, Pfizer, Bayer, Tempus

Drs. John Sweetenham and Angela DeMichele discuss potentially ground-breaking abstracts in breast and lung cancer as well as notable research on artificial intelligence and its impact on cancer care, all of which were featured at the 2024 ASCO Annual Meeting.  TRANSCRIPT Dr. John Sweetenham: Hello, I'm Dr. John Sweetenham from UT Southwestern's Harold C. Simmons Comprehensive Cancer Center and host of the ASCO Daily News Podcast. My guest today is Dr. Angela DeMichele, the Marianne and Robert McDonald Professor in Breast Cancer Research and co-leader of the Breast Cancer Program at the University of Pennsylvania's Abramson Cancer Center. Dr. DeMichele also served as the chair of the 2024 ASCO Annual Meeting Scientific Program. Today, she'll be sharing her reflections on the Annual Meeting and we'll be highlighting some advances and innovations that are addressing unmet needs and accelerating progress in oncology.  Our full disclosures are available in the transcript of this episode.  Dr. DeMichele, congratulations on a very robust and highly successful program at ASCO24, and thanks for joining us on the podcast today. Dr. Angela DeMichele: Well, thanks so much for having me, Dr. Sweetenham. It's a pleasure to be here.  Dr. John Sweetenham: The presidential theme of the Annual Meeting this year was the "The Art and Science of Cancer Care: From Comfort to Cure." And this was certainly reflected throughout the meeting in Chicago that welcomed more than 40,000 attendees from across the globe. I know our listeners will be interested to hear some of your own reflections from the meeting now that we're on the other side of it, so to spea  Dr. Angela DeMichele: Yes. Well, I will say that playing this role in the annual meeting really was a highlight of my career, and I feel so fortunate to have had the opportunity to do it. We had over 200 sessions, and in many, if not all of these sessions, we really tried to make sure that there was a case that really sort of grounded the session to really help people understand: you're going to hear about science, but how are you going to apply that? Who is the patient for whom this science really is important?  We had over 7,000 abstracts submitted, and our 25 tracks and their chairs really pulled through to find really the best science that we could present this year. I think what you saw really was a representation of that across the board: incredible advances in lung cancer, breast cancer, melanoma, GI cancers; also really cutting-edge technologies: AI, as we'll talk about in a little while circulating markers like ctDNA, new drug development, new classes of drugs. So it was really an exciting meeting. I mean, some highlights for me, I would say, were certainly the Plenary, and we can talk a little bit about that. Also, we had a fantastic ASCO/AACR Joint Session on “Drugging the “Undruggable Target: Successes, Challenges, and the Road Ahead.” And, if any of the listeners have not had a chance to hear this, it's really worth going in and watching this because it really brought together three amazing speakers who talked about the successes in KRAS, and then really, how are we using that success in learning how to target KRAS to now targeting a variety of other previously thought to be undruggable targets. I learned so much. And there's really both the academic and the pharma perspective there. So I'd really encourage watching this session. The other session that I really thought was terrific was one that I was honored to chair, which was a fireside chat (“How and Where Will Public Investment Accelerate Progress in Oncology? A Discussion with the NIH and NCI Directors”) with both Dr. Monica Bertagnolli, who is the director of the NIH, and Dr. Kim Rathmell, who's now the director of the NCI. And boy, I'll tell you, these two incredibly smart, thoughtful, insightful women; it was a great conversation. They were really understanding of the challenges we face conducting research, practicing medicine. And maybe different from leadership at the NIH in the past, they've really taken the approach to say that everything they do is focused on the patient, and they don't limit themselves to just research or just science, that everything that the NIH does, and particularly the NCI does, really has to be focused on making sure we can give patients the best possible care. And I think they're being very thoughtful about building important infrastructure that's going to take us into the future, incorporating AI, incorporating new clinical trial approaches that are going to make it faster and easier to conduct clinical trials and to get the results that we need sooner. So just a few of the highlights, I think, from some really interesting sessions. Dr. John Sweetenham: It certainly was an extremely enriching and impactful ASCO24. And I think that the overall theme of the meeting was extremely well reflected in the content with this amazing mix of really, truly impactful science, along with a great deal of patient-centered healthcare delivery science to accompany it. So, I completely agree with you about that. There was a lot, of course, to take in over the five days of the meeting, but I'm sure that our listeners would be very interested to hear about one or two abstracts that really stood out for you this year.  Dr. Angela DeMichele: Sure. I'm a breast cancer specialist, so I can't help but feel that the late breaking abstract, the DESTINY-Breast06 trial, was really important for the field of breast cancer. So just briefly, this is a study of the antibody drug conjugate T-DxD, trastuzumab deruxtecan. This is a drug that is actually now approved in metastatic breast cancer, really effective in HER2-positive disease. But the question that this trial was trying to answer is, can this drug, which is built with the herceptin antibody against HER2, then linked to a chemotherapeutic molecule, can this work even in the setting of very, very low HER2 expression on a tumor? I think this is an incredibly important question in the field of antibody drug conjugates, of which there are now many across diseases, is how much of the target do you really need to have on the surface of the tumor?  We had seen previously HER2 overexpressing tumors respond really well to this drug. HER2 tumors that have an intermediate level of expression were tested in the DP04 trial, and we saw that even those 2+ intermediate tumors responded well to this drug. The DP06 trial that was presented at ASCO was looking at this group of patients that have even less HER2 on the surface. So we typically measure HER2 by immunohistochemistry as 0, 1+, 2+, or 3+. And this was looking at patients whose tumors were over 0, but were at 1+ or below, so low and ultra-low. And it turned out that compared to treatment of physician's choice, the drug really had quite a lot of activity, even in these patients who have very little HER2 on their tumors, really showing progression-free survival benefits in the HER2-low and HER2-ultra-low groups that were appreciable on the order of about 5 months, additional progression free survival hazard ratios around 0.6, so really demonstrating that utilizing an antibody drug conjugate, where you've got very little target, can still be a way to get that drug to a tumor.   And I think it'll remain to be seen whether other ADCs can have activity at very low levels of IHC expression of whatever target they're designed against. I think one of the tricky things here for implementing this in breast cancer will be how do pathologists actually identify the tumors that are ultra-low because it's not something that we typically do. And so we'll go through a period, I think, of adjustment here of really trying to understand how to measure this. And there are a bunch of new technologies that I think will do a better job of detecting low levels of the protein on the surface of the tumor because the current IHC test really isn't designed to do that. It was only designed to be focused on finding the tumors that had high levels. So we have some newer technologies with immunofluorescence, for example, that can really get down to very low levels. And I think this is going to be a whole new area of ADCs, target detection – how low can you go to still see activity? So I thought that this was an important abstract for many reasons.  I will just say the second area that I was really particularly impressed with and had a big impact on me were the two lung cancer abstracts that were presented in the Plenary, the LAURA trial (LBA4) and the ADRIATIC trial (LBA5). And I think, I've been in the field of oncology for 30 years now, and when I started in the late ‘90s, lung cancer was a disease for which we had very few treatments. If we didn't catch it early and surgery wasn't possible for non-small cell lung cancer, really, it was a horrible prognosis. So we knew this year was the 20th anniversary of the discovery of EGFR as a subtype of lung cancer. That was really, I think, a turning point in the field of non-small cell lung cancer – finding a target. And now seeing the LAURA trial show that osimertinib really had such an enormous impact on progression-free survival amongst these patients who had EGFR-positive non-small cell lung cancer, progression-free survival hazard ratio of 0.16; there was a standing ovation.  And one of the really big privileges of being the Scientific Program Chair is getting to moderate the Plenary Session, and it's a really amazing experience to be standing up there or sitting there while the presenter is getting a standing ovation. But this was well deserved because of the impact this is having on patients with EGFR positive lung cancer. And it was similar with the ADRIATIC trial, which looked at the benefits of adding immunotherapy in limited-stage small-cell lung cancer. Again, a disease that treatment has not changed in 30 years, and so the addition of durvalumab to the standard backbone of chemotherapy for small cell lung cancer had its survival advantage. These patients are living longer and it was really an impressive improvement. And I think it really underscores just the revolution that has happened in lung cancer between targeted therapy and immunotherapy has completely changed the prognosis for patients with this disease. So to me, these were really landmark reports that came out at ASCO that really showed us how far we've come in oncology. Dr. John Sweetenham: Yeah, absolutely. I think that, as you mentioned, those results are truly remarkable, and they reflect extraordinary advances in science. I think we see that both in terms of the therapeutic arena, but also, I think we've started to see it in other areas as well, like symptom control, remote patient monitoring, and so on and so forth, where some of the newer virtual technologies are really having major impacts as well. Dr. Angela DeMichele: Yes, we really wanted to have a focus on artificial intelligence in this meeting, because it's having such an enormous impact on our field in everything from care delivery to diagnostics. I'd love to hear what you thought was the most interesting, because there really was just new data across the board presented. Dr. John Sweetenham: I've actually chosen 3 abstracts which I thought were particularly interesting for a couple of reasons, really. They're all based on virtual health interventions, and I think they're interesting in really reflecting the theme of the meeting, in that they are extremely advanced technology involved in the virtual platforms, a couple of which are artificial intelligence, but very impactful to patients at the same time in terms of remote symptom control, in terms of addressing disparities, and in one case, even influencing survival. So I thought these were three really interesting abstracts that I'll walk the listeners through very quickly.  The first of these was a study, Abstract 1500 (“National implementation of an AI-based virtual dietician for patients with cancer”) which looked at an artificial intelligence-based virtual dietitian for patients with cancer. This is based on the fact that we know nutritional status to be a key driver of patient experience and of cancer outcomes. And as the authors of the presentation noted, 80% of patients look for nutritional support, but many of them don't get it. And that's primarily a workforce issue. And I think that's an important thematic point as well, that these new technologies can help us to address some of the workforce issues we have in oncology. So this was an AI-based platform developed by experts in nutrition and cancer patients, based on peer reviewed literature, and a major effort in terms of getting all of these data up together. And they developed an artificial intelligence platform, which was predominantly text message based. And this platform was called INA. And as this is developing as a platform, there's a machine learning component to it as well. So in theory, it's going to get better and better and better over time.  And what they did in their study was they looked at little over 3,000 patients across the entire country who were suffering from various types of cancer, GU, breast, gynecological malignancy, GI and lung. And most of them had advanced-stage disease, and many of them had nutritional challenges. For example, almost 60% of them were either overweight or obese by BMI. And the patients were entered into a text exchange with the AI platform, which would give them advice on what they should eat, what they shouldn't eat. It would push various guidance and tips to them, it would develop personalized recipes for them, and it would even develop menu plans for the patients. And what's really interesting about this is that the level of engagement from the patients was very high, with almost 70% of patients actually texting questions to this platform. About 80% of the patients completed all of the surveys, and the average time that patients interacted with the platform was almost nine months, so this was remarkable levels of engagement, high levels of patient satisfaction. And although at this point, I think it's very early and somewhat subjective, there was certainly a very positive kind of vibe from patients. Nearly 50% have used the recommended recipes. More than 80% of them thought that their symptoms improved while they were using this platform. So I think as a kind of an assistant for remote management of patients, it's really remarkable. And the fact that the level of engagement was so high also means that for those patients, it's been very impactful.   The second one, this was Abstract 100 (“AI virtual patient navigation to promote re-engagement of U.S. inner city patients nonadherent with colonoscopy appointments: A quality improvement initiative”) looked again at an AI-based platform, which in this case was used in an underserved population to address healthcare disparities. This is a study from New York which was looking at colorectal cancer screening disparities amongst an underserved population, where historically they've used skilled patient navigators to address compliance with screening programs, in this case specifically for colorectal cancer. And they noticed in the background to this study that in their previous experience in 2022, almost 60% of patients either canceled or no-showed for colonoscopy appointments. And because of this and because of the high burden of patients that this group has, they decided to take an AI-based virtual patient navigator called MyEleanor and introduce this into their colorectal cancer screening quality improvement.  And so they introduced this platform in April of 2023 through to the end of the year, and their plan was to target reengagements of around 2,500 patients who had been non adherent with colonoscopy appointments in a previous year. And so the platform MyEleanor would call the patients to discuss rescheduling, it would assess their barriers to uptake, it would offer live transfer to somebody to schedule for them, and then it would go on closer to the point of the colonoscopy to call the patients and give them advice about their prep. And it was very nuanced. The platform would speak in both English and Spanish versions. It could detect nuances in the patient's voice, which might then trigger it to refer the patient to a live agent rather than the AI platform. So, very sophisticated technology. And what was most interesting about this, I think, was that over the eight months of the study, around 60% of patients actually engaged with this platform, with almost 60% of that group, or 33% overall, accepting a live transfer and then going on to scheduling, so that the completion rate for the no show patients went from 10% prior to the introduction of this platform to 19% after it was introduced. So [this is] another example, I think, of something which addresses a workforce problem and also addresses a major disparity within cancer care at the moment by harnessing these new technologies. And I think, again, a great interaction of very, very high-level science with things that make a real difference to our patients.  So, Dr. DeMichele, those are a couple of examples, I think, of early data which really are beginning to show us the potential and signal the impact that artificial intelligence is going to have for our patients in oncology. I wonder, do you have any thoughts right now of where you see the biggest impact of artificial intelligence; let's say not in 20 years from now, but maybe in the next year or two?  Dr. Angela DeMichele: Well, I think that those were two excellent examples. A really important feature of AI is really easing the workload on physicians. And what I hope will happen is that we'll be able to use AI in the very near future as a partner to really offload some of the quite time-consuming tasks, like charting, documentation, that really take us away from face-to-face interaction with patients. I think this has been a very difficult period where we move to electronic medical records, which are great for many reasons, but have really added to the burden to physicians in all of the extra documentation. So that's one way, I think, that we will hope to really be able to harness this. I think the other thing these abstracts indicate is that patients are very willing to interact with these AI chatbots in a way that I think, as you pointed out, the engagement was so high. I think that's because they trust us to make sure that what we're doing is still going to be overseen by physicians, that the information is going to get to us, and that they're going to be guided. And so I think that in areas where we can do outreach to patients, reminders, this is already happening with mammograms and other sorts of screening, where it's automated to make sure you're giving reminders to patients about things that they need to do for some of their basic health maintenance. But here, really providing important information – counseling that can be done by one of these chatbots in a way that is compassionate, informative and does not feel robotic to patients.   And then I was really impressed with, in the abstract on the screening colonoscopy, the ability of the AI instrument to really hear nuances in the patient's responses that could direct them directly to a care provider, to a clinician, if they thought that there might be some problem the patient was experiencing. So again, this could be something that could be useful in triaging phone calls that are coming in from patients or our portals that just feel like they are full of messages, no matter how hard you try to clear them all out, to get to them all. Could we begin to use AI to triage some of the more mundane questions that don't require a clinician to answer so that we can really focus on the things that are important, the things that are life threatening or severe, and make sure that we're getting to patients sooner? So there's just a few ways I really hope it'll help us. Dr. John Sweetenham: Yeah, absolutely. I think we're just scratching the surface. And interestingly enough, in my newsfeed this morning through email, I have an email that reads, “Should AI pick immunotherapy combinations?” So we'll see where that goes, and maybe one day it will. Who knows? Dr. Angela DeMichele There was a great study presented at ASCO about that very thing, and I think that is still early, but I could envision a situation where I could ask an AI instrument to tell me all of the data around something that I want to know about for a patient that could deliver all of the data to me in real time in the clinic to be able to help me make decisions, help me quote data to patients. I think in that way it could be very, very helpful. But it'll still need the physicians to be putting the data into context and thinking about how to apply it to the individual person. Dr. John Sweetenham: Absolutely, yes. And so just to round off, the final abstract that caught my eye, which I think kind of expands on a theme that we saw at an ASCO meeting two or three years ago around the impact of [oncology] care at home, and this was Abstract 1503 (“Acute care and overall survival results of a randomized trial of a virtual health intervention during routine cancer treatment”). So, a virtual platform but not AI in this case. And this was a study that looked at the use of an Integrative Medicine at Home virtual mind-body fitness program. And this was a platform that was used to look at hospital admission and acute care of patients who used it, and also looked at survival, interestingly enough. So what was done in this study was a small, randomized study which looked at the use of virtual live mind, body and fitness classes, and compared this in a randomized fashion to what they called enhanced usual care, which essentially consisted of giving the patients, making available to the patients, some pre-recorded online meditation resources that they could use. And this was applied to a number of patients with various malignancies, including melanoma, lung, gynecologic, head and neck cancers, all of whom were on systemic therapy and all of whom were reporting significant fatigue.  This was a small study; 128 patients were randomized in this study. And what was very interesting, to cut to the chase here, is that the patients who had the virtual mind-body program, compared with the control group, actually were less likely to be hospitalized, the difference there being 6.3% versus 19.1%, respectively. They spent fewer days in the hospital. And remarkably, the overall survival was 24.3 months median for patients in the usual care arm and wasn't reached in those patients who were on the virtual mind-body fitness class platform. So very preliminary data, certainly are going to need more confirmation, but another example of how it appears that many of these non-pharmacological interventions have the potential to improve meaningful endpoints, including hospital stays and, remarkably, even survival. So again, I think that that is very consistent with the theme of this year's meeting, and I found that particularly interesting, too.  I think our time is up, so I want to thank you, Dr. DeMichele, for sharing your insights with us today on the ASCO Daily News Podcast. We really appreciate it. And once again, I want to congratulate you on what was really a truly remarkable ASCO this year.  Dr. Angela DeMichele: Well, thanks so much for having me. It's been a tremendous pleasure to be with you today. Dr. John Sweetenham: And thank you to our listeners for joining us today. You'll find links to the abstracts discussed today in a 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.   Follow ASCO on social media:    @ASCO on Twitter    ASCO on Facebook    ASCO on LinkedIn      Disclosures:   Dr. John Sweetenham:   Consulting or Advisory Role: EMA Wellness  Dr. Angela DeMichele: Consulting or Advisory Role (an immediate family member): Pfizer Research Funding (Inst.): Pfizer, Genentech, Novartis, Inviata/NeoGenomics  

SHINING WITH ADHD  EPISODE #155: Med Shortages, Melatonin and More: A Pediatrician's Perspective on ADHD with Dr. Mona Amin 5/8/2024 SUMMARY We often talk about how supporting kids with ADHD takes a village. Building your child's team of professionals is SO important. From educators to therapists and pediatricians, their experience and understanding are key to helping kids shine. Today, on the podcast, we have Dr. Mona Amin. She is a board-certified pediatrician, parenting coach, and mother. In this episode, she shares her perspective on current med shortages, using melatonin, and collaboration between providers.  MEET DR. MONA Dr. Mona Amin is a board-certified general pediatrician, lactation educator, parenting coach, and mother. She has been featured on Parents.com, Good Morning America, ABC Nightly News, Romper, CondeNast Traveler, VeryWell Family, and NBC News. She works in private practice, and her passions include early childhood development, focusing on the impact of healthy sleep, a healthy relationship with food, and healthy coping skills in the first seven years of a child's life. She has parenting and how-to-courses to guide parents from birth to 4 years, including social media channels on Instagram and TikTok, a Top 50 Parenting Podcast, and a YouTube Channel. Through her brand, PedsDocTalk, her goal is to provide relatable and easy-to-digest education for the modern parent regarding the health, safety, and wellness of their child so they can have a more confident and calm parenting journey. Her platform aims to guide parents in a mindful way to be the best version of themselves for their children. OFFERS AND AFFILIATE INFORMATION Creating Calm is a video-based course that will teach you simple, step-by-step strategies to help you parent a happy and independent child with ADHD (ages 4-12 years old). Whenever and wherever you have an internet connection. Use the code PODCAST for 10% off!   Hungryroot offers “good-for-you groceries and simple recipes.” We have loved having one less thing to worry about when it comes to raising kids. As always, we want to help you, so we've got a code for 40% off your first box.  Just click the link and use CHILDHOODCOLLECTIVE40 in all caps to get the discount.    We LOVE the Zenimal. It's amazing for kids who are feeling anxious or need a little help calming their busy body before bed. The best part? Each meditation ends with the most beautiful message: “You're a good kid!” Use our code: TCC for a discount. LINKS + RESOURCES Episode 155 Transcript Dr. Mona's Podcast and Courses Creating Calm - Code PODCAST Hungry Root - Code CHILDHOODCOLLECTIVE40 Zenimal - Code TCC The Childhood Collective Instagram Have a question or want to share some thoughts? Shoot us an email at hello@thechildhoodcollective.com