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Cancer.Net Podcasts

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Cancer.Net Podcasts are special audio versions of Cancer.Net's award-winning content on cancer research, treatment, coping, and many other topics.

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Cancer.Net Podcasts are special audio versions of Cancer.Net's award-winning content on cancer research, treatment, coping, and many other topics.

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Cancer.Net Podcasts

Latest release on Feb 13, 2020

The Best Episodes Ranked Using User Listens

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Rank #1: Fasting and Cancer, with Suzanne Dixon, MPH, MS, RDN and Annette Goldberg, MS, MBA, RDN, LDN

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To fast is to partially or completely reduce one’s food intake for a period of time. In today’s podcast, Suzanne Dixon and Annette Goldberg discuss the history of fasting, different types of diets, and why some scientists are researching the effects of fasting during or after cancer treatment. They also provide tips for someone considering fasting during treatment.  

Quality of Life

Oct 06 2016

18mins

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Rank #2: CT Scan - What to Expect

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This podcast explains what to expect during a computed tomography, or CT, scan.

Treatments, Tests, and Procedures

Jan 02 2012

5mins

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Rank #3: Look Good...Feel Better, with Mary Jane Massie, MD

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Mary Jane Massie, MD, discusses the Look Good...Feel Better program from the Personal Care Products Council Foundation. Look Good...Feel Better offers free support programs across the country for women with cancer.

Quality of Life

Sep 24 2008

9mins

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Rank #4: 2019 ASCO Annual Meeting Research Round Up: Breast Cancer, Head and Neck Cancer, and Cancer-Related Nausea and Vomiting

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ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses.

The 2019 ASCO Annual Meeting, held May 31 to June 4, brought together physicians, researchers, patient advocates, and other health care professionals from around the world to present and discuss the latest research in cancer treatment and patient care. In the annual Research Round Up podcast series, Cancer.Net Associate Editors share their thoughts on the most exciting scientific research to come out of this year’s ASCO Annual Meeting and what it means for patients.

First, Dr. Lynn Henry will discuss 3 studies that explored new treatment options for women with breast cancer, including a study on immunotherapy for triple-negative breast cancer and 2 studies on treatment for hormone receptor positive, HER2-negative breast cancer. She also discusses research on the effects of a low-fat diet in women diagnosed with breast cancer, and a study on whether pregnancy after breast cancer increased the risk of recurrence.  

Dr. Henry is an Associate Professor and Interim Division Chief of Oncology in the Department of Medicine at the University of Utah and Director of Breast Medical Oncology at the Huntsman Cancer Institute. She is also the Cancer.Net Associate Editor for Breast Cancer.

Dr. Henry: Hi. My name is Dr. Lynn Henry. I'm a medical oncologist who specializes in treating breast cancer at the University of Utah. Today, I'm going to discuss research on breast cancer that was presented at the 2019 ASCO Annual Meeting in Chicago. In particular, I'm going to focus on the results of some clinical trials that directly impact how oncologists treat patients with breast cancer. First, I'm going to give just a very brief overview of the types of breast cancer and then talk about some research that was presented on triple-negative and hormone-receptor-positive breast cancer. Then I'm going to briefly review findings related to diet and breast cancer as well as pregnancy after breast cancer in women with BRCA mutations.

As a quick reminder, there are multiple kinds of breast cancer. Some breast cancers are called hormone-receptor positive or estrogen-receptor positive, and those are stimulated to grow by estrogen. We treat those cancers with anti-estrogen treatments or anti-hormone treatments to block estrogen or lower the estrogen level in the body. Other breast cancers are called HER2-positive. These are often more aggressive cancers. But because they have extra copies of HER2, they often respond to treatments that block HER2. And finally, there are breast cancers that don't have hormone receptors or HER2, and these are called triple-negative breast cancer.

So first, I'm going to focus on this type, triple-negative breast cancer. Until recently, most of the time, we treated triple-negative breast cancer with chemotherapy because we hadn't found other drugs that worked very well. There's a new type of drug, however, called immunotherapy that tries to use a patient's immune system to help fight the breast cancer. Early in 2019, the FDA approved a new treatment for triple-negative breast cancer that is a combination of a chemotherapy called Abraxane and a new immune drug called atezolizumab or Tecentriq. The combination increased the length of time until cancer progressed or grew. Overall, the treatment was fairly well tolerated. But we did learn that in order for the treatment to work, the cells surrounding the cancer have to have at least a small amount of a very specific protein called PD-L1.

So at this recent ASCO meeting, we heard an update about this treatment. In the trial, the patients whose cancers had the PD-L1 protein and who got the combination treatment lived 7 months longer than those who got just the chemotherapy, which was an increase from 18 months to just over 2 years. This is an important first step towards finding a better treatment for this difficult type of triple-negative breast cancer. And this treatment is currently available to patients. Additional clinical trials are going on now to try to find even better combinations of chemotherapy and immune therapies to treat this type of cancer.

So next, I'm going to talk about hormone-receptor-positive breast cancer. There were two trials of this type of cancer that had important results presented at the ASCO meeting. First, I'll focus on the treatment of early-stage node-negative breast cancer that is hormone-receptor positive and HER2 negative. The Oncotype DX test is a test we commonly run on tumors of this type to help determine whether treatment with chemotherapy is likely to be helpful. For this test, if your tumor has a score over 25, then chemotherapy is generally recommended in addition to anti-hormone therapy. If you have a score under 11, then chemotherapy is not recommended and a patient should receive only anti-hormone therapy. But for those with scores between 11 and 25, it was unclear how beneficial it was to receive chemotherapy. Last year, the results of the TAILORx trial were reported. And that showed that for women over the age of 50, if their tumor had a score between 11 and 25, they were not likely to get benefit from chemotherapy. However, it turned out it was a bit more complicated for women aged 50 and under. For those with scores between 11 and 15, chemotherapy was not likely to be beneficial. However, for those who score 16 to 25, chemotherapy might be beneficial. So we got some answers but not everything.

At this recent ASCO meeting, additional information was reported to help guide treatment decision making for this middle group of women aged 50 and under. So for women whose scores were at the higher end, 21 to 25, chemotherapy was found to be likely to be beneficial. However, in that middle group, the 16 to 20 group, chemotherapy might be beneficial but generally only for women with higher risk cancers, meaning larger cancers or higher grade. This information is helpful because it provides more information for oncologists and for patients when they are discussing whether or not chemotherapy should be included as part of their treatment.

So switching gears a little, still staying with premenopausal women and hormone-receptor-positive HER2-negative cancer, but now thinking about metastatic breast cancer, so cancer that has spread. We now have additional information about treatment with an anti-hormone therapy plus an additional drug called the CDK4/6 inhibitor. We've routinely been recommending this treatment combination because it leads to a longer time before the cancer progresses. But until now, we didn't know if it actually allows women with this type of cancer to live longer. The results of the MONALEESA-7 trial, which looked at the combination of an anti-hormone therapy plus the drug called ribociclib, showed that women who received the combination instead of anti-hormone therapy alone live almost 30% longer. So looking at women 3 and a half years after they started treatment, just over 70% of the women who were treated with ribociclib plus anti-hormone therapy were alive compared to just under half of women treated with anti-hormone therapy alone. So these results reinforce that this is an excellent first approach to treatment of premenopausal women who have newly diagnosed, hormone-receptor-positive HER2-negative metastatic breast cancer.

So in addition to studies looking at these specific types of breast cancer, there were 2 other interesting studies that were applicable to breast cancer more generally. So there was a large study that was reported that looked at whether having a low-fat diet reduced the likelihood of developing triple-negative breast cancer. So in this study, postmenopausal without cancer were randomized to either a low-fat diet or their usual diet and followed for many, many years. Over time, some of these women developed breast cancer with no difference between those who followed the low-fat diet or the regular diet. However, in this new report, they looked specifically at the women who developed breast cancer who were enrolled in this trial. Fewer women died from their breast cancer if they ate the low-fat diet, especially if they had preexisting high cholesterol, diabetes, and obesity. These findings suggest that having a low-fat diet may actually reduce the risk of dying overall and also specifically from breast cancer. Now, these need to be validated, and we don't quite understand why this would be the case. But in general, it seems like having a low-fat diet, avoiding high cholesterol, diabetes, and obesity is a good thing.

And then finally, 1 question that comes up often is whether it is safe to have a baby after the diagnosis of breast cancer. This is especially concerning for patients who have a mutation in genes called BRCA1 or BRCA2 since those mutations greatly increase their risk of developing both breast and ovarian cancer and also leads to the diagnosis of breast cancer at an early age. In addition, patients with these mutations are often recommended to have their ovaries removed at a young age. So in this study, patients who became pregnant did so about 4 and a half years after they were diagnosed with breast cancer. There was no apparent increase in miscarriage, preterm birth, or birth defects compared to what would be expected in women without cancer. And in the patients, there was no increase in the risk of breast cancer recurrence compared to those who did not become pregnant. And in fact, those who became pregnant were slightly less likely to have their cancer return, especially those who had mutations in BRCA1. So while there are some limitations to the study, the findings are reassuring that there does not appear to be an increase in risk of breast cancer returning in these patients with BRCA mutations who become pregnant after breast cancer diagnosis.

So overall, as you can see, there's a lot of exciting research going on across all the different subsets of breast cancer. The results of many important clinical trials were reported at the recent ASCO meeting, and there are many more trials ongoing that will hopefully result in the approval of multiple new effective treatments for breast cancer. In addition, there's research going on examining the impact of treatment on patients with breast cancer and trying to improve the lives of those living with breast cancer. Clinical trials are critical for the development of these new treatments.

Well, that's it for this quick summary of this important research from ASCO 2019. Overall, we continue on a fast track in breast cancer, with many new and exciting therapies being actively studied and research helping support our patients do better than ever before. Stay tuned to Cancer.Net for future updates from upcoming breast cancer conferences. Thank you very much.

ASCO: Thank you, Dr. Henry.

Next, Dr. Ezra Cohen will discuss several studies that looked at using immunotherapy and targeted therapy to treat different types of head and neck cancer. Dr. Cohen is Associate Director of Translational Science and leads the Solid Tumor Therapeutics research program at Moores Cancer Center at UC San Diego Health. He is the Cancer.Net Associate Editor for Head and Neck Cancer.

Dr. Cohen: Hi. I'm Dr. Ezra Cohen from UC San Diego Moores Cancer Center. Today, I'm going to talk about research on head and neck cancer that was presented at the 2019 ASCO Annual Meeting. I think the most impactful presentation at the meeting was a follow-up on the KEYNOTE-048 study, which implemented the drug pembrolizumab, an anti-PD-1 antibody in first-line recurrent metastatic head and neck cancer. These were patients who were treated with curative intent or presented with metastatic disease, and either way, either had recurrence or eventually developed metastases.

The first-line standard of care for these patients used to be the so-called extreme regimen, which involved platinum, 5-FU, and cetuximab. This was validated in an earlier phase III study that was conducted about 10 years ago and was the approved first-line regimen for these patients. In KEYNOTE-048, this extreme regimen was tested against either pembrolizumab alone or pembrolizumab, platinum, and 5-FU, in other words, substituting cetuximab for pembrolizumab in one of the experimental arms.

We'd initially seen the interim analysis data at last year's ESMO meeting, but this year, we have the final analysis presented at ASCO. And what we saw was that both experimental arms actually achieved an improvement in overall survival compared to the extreme regimen. Interestingly, for pembrolizumab alone, this occurred in patients whose tumors expressed some level of PD-L1. That was evaluated by something called the composite score and takes into account both stromal and tumor cell staining of PD-L1. In fact, even at a very low level—that is CPS greater than or equal to 1—pembrolizumab monotherapy was superior to the extreme regimen with respect to overall survival. For all patients, the regimen of pembrolizumab plus chemotherapy was superior to the extreme regimen irrespective of PD-L1 staining.

What we saw at this year's ASCO meeting was that, in fact, first, the higher the expression of PD-L1, the greater the benefit one derived from pembrolizumab either as monotherapy or in combination with chemotherapy. And in patients who had higher levels of PD-L1 and received both pembrolizumab and chemotherapy, the overall survival was quite remarkable with a hazard ratio of just higher than 0.6. In fact, we now have FDA approval in the United States for pembrolizumab monotherapy with tumors that have some expression level of PD-L1—that is CPS greater than or equal to one—or for all comers in patients who either the CPS status is unknown or patients whose tumors don't express PD-L1.

Beyond KEYNOTE-048, we saw interesting data in first-line recurrent metastatic using a regimen of taxane, platinum, and 5-FU compared to the same extreme regimen that we just mentioned. That regimen turned out to be much better tolerated with fewer adverse events but with no improvement in overall survival, giving us a regimen that we could substitute for the extreme regimen if one wanted to, realizing that it does not involve immunotherapy, and for some patients, this may still be an appropriate treatment.

Beyond the first-line recurrent metastatic studies, we saw a few interesting trials looking at targeted therapy in head and neck cancer but specific subsets. The first was in patients whose tumors expressed HER2 at very high levels—that is HER2 amplified—and had salivary ductal carcinoma. We've known that a proportion of salivary ductal carcinoma patients' tumors amplify this gene, HER2, similar to breast cancer and some other malignancies and that trastuzumab may, in fact, be effective. Well, in this study conducted by the Memorial Sloan Kettering Group, an antibody-drug conjugate trastuzumab emtansine was employed as a single agent in these patients whose, again, tumors amplified HER2. And what they saw was a remarkable 90% response rate. Now, this was only in 10 patients, so the study is small, but I think it's safe to say that this drug appears to be quite effective in patients with HER2-amplified salivary ductal carcinoma.

Along those lines, in the subset of thyroid cancer patients whose tumors either mutate or have a RET fusion, the gene RET, there appeared to be very high efficacy for a novel agent that targets the RET oncogene. This was in both patients with medullary thyroid cancers that often have a RET mutation or in papillary thyroid cancers whose tumors often have a fusion of the same RET gene. Again, underscoring the idea that if we can target a driver even in a relatively small subset of patients, the benefit may be quite large. Along those lines, we had seen prior data for track inhibitors in patients who have in track fusions. And again, this applies to subsets of head and neck cancer patients that have either salivary gland cancers or thyroid cancers.

Lastly, we continue to see emerging promising data of combinations with immunotherapy, and 2 highlights from ASCO were pembrolizumab with cetuximab showing a response rate of over 40% in a small group of patients and pembrolizumab with a TLR9 agonist called SD-101 showing about a 30% response rate. Of course, these data are very early and uncontrolled, and so we have to follow these stories further along to see if, indeed, these early signs of efficacy turn out to validate. But the idea that further combinations of immunotherapies eventually making their way to larger studies and hopefully approval is now well enforced in head and neck cancer. Thank you very much for your attention and hope you enjoyed the ASCO 2019 Annual Meeting.

ASCO: Thank you Dr. Cohen.

Next, Dr. Charles Loprinzi will discuss new research on ways to prevent or treat nausea and vomiting caused by cancer treatment. Dr. Loprinzi is a medical oncologist and the Regis Professor of Breast Cancer Research at the Mayo Clinic. He is also the Cancer.Net Associate Editor for Psychosocial Oncology.

Dr. Loprinzi: Hello, I'm Charles Loprinzi, Regis Professor of Breast Cancer Research at Mayo Clinic. I'm going to be talking today about chemotherapy-induced nausea and vomiting. Now, chemotherapy can cause a lot of nausea and vomiting. That's well known, for years and years, by many people. It's not all types of chemotherapy, but some chemotherapy drugs cause a lot of nausea and vomiting, and others cause little to none. It's not as big a problem now as it was decades ago when we didn't have good drugs to try to prevent nausea and vomiting. Many drugs over the time have been developed for trying to prevent this nausea and vomiting problem. Examples of the drugs that cause a lot of nausea and vomiting are Cisplatinum, and Adriamycin and cyclophosphamide is a combination that is oftentimes used for patients with breast cancer.

So in the past, we have developed many, many drugs for this. Three of the drugs that have commonly been used for the last many, many years for treatment or prevention of nausea and vomiting associated with chemotherapy are corticosteroid medications like Dexamethasone. It's quite cheap. It's got some side effects, but relatively cheap. Then there's a group called 5-HT3 receptor antagonists. I didn't make up that name, but that's the long name for it. They're relatively expensive, some more expensive than other ones. And then there's another group called NK1 receptor antagonists, and they can be quite expensive, sometimes being hundreds of dollars for each dose that's given to try to prevent nausea and vomiting related to chemotherapy.

So a couple years ago, 2016, there was a report in the New England Journal of Medicine, which is a prominent journal for us in the business, that looked at a drug called olanzapine. It's a relatively cheap drug. It's a drug that was developed for psychosis-type problems, given for long term in those patients. But it had been noted that if it's given for just a few days, it seems to markedly improve or decrease the instance of nausea and vomiting, or if people were having nausea and vomiting, it appears actually to help and reverse that particular problem.

So this trial looked at 10 milligrams of this drug for 4 days, given before chemotherapy, and then for 3 more days after that. Patients who were on this study got the 3 drugs that I talked about before with the olanzapine or with the placebo. And it noted that it improved things by quite a bit. The patients who had what we call a complete response, which means no vomiting and no need to take extra medications because of nausea and vomiting, improved from 41% of the patients who were on the placebo, to 64% who were on the olanzapine, a 23% improvement.

And if we looked at a different endpoint there, the number of patients who had no nausea during the five days after chemotherapy, it was 22% in the group that got the placebo and improved to 37% in the group that didn't. So it was a good result in that area. One of the problems with this drug is that it can cause some sedation, cause some drowsiness for some patients. Most patients, not much, but some patients, it's a problem.

So most trials that have been done in the past use this 10-milligram dose. And what we learned at ASCO in 2019, our main meeting that we have once a year, was that people looked at a 5-milligram dose and had looked at 5 milligrams instead of the 10 milligrams. And what it showed is that the results seemed to be quite similar to what was seen with 10 milligrams. They did the study quite the same as what had been reported in the previous trial and the results looks similar. They didn't compare 5 milligrams versus 10 milligrams, which would've been nice because then we would have better information along that line. They did note that there was drowsiness that some patients had, and it looks similar to what was seen with the 10-milligram dose. But these data support, but don't prove, that giving 5 milligrams does look like it's good in this particular setting.

So data from this year also supported that instead of giving the drug during the day when getting the chemotherapy, sometimes, people take it at bedtime, and there, the drowsiness is not as big a problem because you want to be drowsy at bedtime. So it's not proven that it works as well at bedtime, but it suggests that that actually is the case.

Data from this year also supported that if you looked at those 3 drugs I mentioned before and just took out that 1 really, really expensive one, the NK1 receptor antagonist, and put the olanzapine in there instead, that very cheap medication, that that looked like that one with the olanzapine did better than the very expensive one. Not a whole lot better; they looked similar, but a little bit better in that setting, and it was a whole lot cheaper. This was also seen in a publication that came out a couple of years ago which showed the same sort of result. Again, not proof that it's beneficial, that it's okay to do that, but it looked better.

So the next obvious question that comes up then is when you have these 4 drugs that you give, the 3 drugs I mentioned before and this fourth one, what about if you take away that more expensive one and see how they do there? So there was a trial at the ASCO meeting that suggested that the addition of that expensive medications didn't provide a whole lot more benefit. Right now, there is a trial going on across the United States, with about 800 patients who are scheduled to go on this trial, and it's approving about 30 patients a month, which is a pretty good accrual rate, which is looking at this particular question where people would get the 4-drug regimen versus 3 drugs where they take away the expensive intravenous medication.

So, in summary, 35 to 40 years ago, when I started my cancer career, when I was about 10 years old, most patients had a lot a trouble with nausea and vomiting with drugs like Cisplatinum. Now, this a minority of patients who have a lot of problems, and we're continuing to find new things that will make things better along this line. Thank you for your attention.

ASCO: Thank you Dr. Loprinzi.

Learn more about these topics and other research presented at the 2019 ASCO Annual Meeting at www.cancer.net.

If this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play. And stay tuned for additional Research Round Up podcasts coming later this summer.

Cancer.Net is supported by Conquer Cancer, the ASCO Foundation, which funds breakthrough research for every type of cancer, helping patients everywhere. To help fund Cancer.Net and programs like it, donate at conquer.org/support.

Jun 25 2019

24mins

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Rank #5: The Role of a Patient Navigator, with Lillie D. Shockney, RN, BS, MAS

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In today’s podcast, Lillie Shockney discusses her article, “The Value of Patient Navigators as Members of the Multidisciplinary Oncology Care Team.” Nurse navigators, also known as patient navigators, help a person with cancer “navigate” the hospital and human services bureaucracies. This includes assisting with decision making, coordinating services, and advocating for the patient with the other members of the health care team. 

Cancer Basics

Nov 14 2016

8mins

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Rank #6: When the Doctor Says Cancer

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In this podcast, we talk about the first steps to take when you are diagnosed with cancer.

Cancer Basics

Oct 31 2011

5mins

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Rank #7: Tips on Caregiving

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What to expect as a caregiver to a person with cancer and tips on effectively giving care.

Family, Friends, and Caregivers

Nov 14 2011

6mins

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Rank #8: Understanding the Ketogenic Diet, with Roy Strowd, MD, and Annette Goldberg, MS, MBA, RDN, LDN

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A ketogenic diet is a high-fat, low-carbohydrate diet that has some specific neurological effects. In today’s podcast, Annette Goldberg talks with Dr. Roy Strowd about this diet, its history, and its potential benefits in people with certain types of brain tumors.

Cancer Research News

Sep 26 2017

16mins

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Rank #9: Physical Activity During and After Cancer Treatment, with Kristen Leung and Rachel Dudasik

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There are many benefits to being physically active during and after cancer treatment. However, the side effects of cancer treatment can make it challenging to get to a gym or complete standard exercises. In this podcast, we discuss these challenges, tips for staying physically active, and the benefits of participating in a fitness program designed for cancer survivors, like LIVESTRONG at the YMCA. 

After Treatment and Survivorship

Oct 31 2017

15mins

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Rank #10: The Role of Art Therapists in Cancer Care, with Michelle Itczak

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Through art therapy, someone with cancer can explore and express feelings that they may not be able to say aloud. In today’s podcast, Michelle Itczak will discuss the role of art therapy in cancer care, and what someone with cancer should know about working with an art therapist. 

Cancer Basics

Apr 20 2017

4mins

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Rank #11: Seeking a Second Opinion

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Getting a second opinion when making cancer treatment decisions.

Cancer Basics

Feb 06 2012

3mins

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Rank #12: 2018 ASCO Annual Meeting Research Round Up: Childhood Cancers, Older Adults, Multiple Myeloma, and Lung Cancer

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ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses.

The ASCO Annual Meeting brings together physicians, researchers, patient advocates, and other health care professionals to discuss the latest in cancer care. The research presented at this meeting frequently leads to treatment advances and new ways to improve the quality of life for people with cancer. In today’s podcast, Cancer.Net Associate Editors share their thoughts on the most exciting and practice-changing news to come out of the 2018 ASCO Annual Meeting.

First, Dr. Daniel Mulrooney will discuss a large international study on maintenance chemotherapy for rhabdomyosarcoma, and several studies on the benefits of physical activity for survivors of childhood cancer. Dr. Mulrooney is an Associate Faculty Member in the Division of Cancer Survivorship at St. Jude Children’s Research Hospital. He is also the Cancer.Net Associate Editor for Childhood Cancers.

Dr. Mulrooney: This is Dr. Dan Mulrooney from St. Jude Children's Research Hospital. I'm the Deputy Director of the After Completion of Therapy Clinic at St. Jude and primarily care for survivors of pediatric solid tumors. During this year's Annual Meeting of the American Society of Clinical Oncology, a very interesting, large, international study investigating maintenance treatment for rhabdomyosarcoma was highlighted during the plenary session. Maintenance chemotherapy, or prolonged low-dose chemotherapy, is used most frequently in the treatment of acute lymphoblastic leukemia, or ALL, but less so for pediatric solid tumors.

In a study conducted by the European Paediatric Soft Tissue Sarcoma Study Group that included patients from 14 different countries, investigators studied adding maintenance chemotherapy to the treatment of high-risk rhabdomyosarcoma. Rhabdomyosarcoma is a rare tumor, which mostly occurs in children but can also present in adults. Fortunately, treatment is often successful. But up to 20 to 30 percent of patients may still relapse after treatment meaning additional treatment is needed and making long-term cure more difficult. Standard treatment involves 6 to 8 months of intensive chemotherapy, radiation, and surgery. These investigators wanted to know if adding additional low-dose chemotherapy for six months after standard treatment might improve survival. They studied patients greater than 6 months to less than 21 years of age with high-risk disease based on the histology and location of their tumors. 186 patients were randomized to standard therapy. And 185 were randomized to receive the additional 6 months of maintenance chemotherapy, which included vinorelbine given IV, weekly, for 3 weeks every month, and cyclophosphamide taken orally everyday. And at 5 years, the overall survival was statistically better in the maintenance chemotherapy group, 87% versus 74% in the standard therapy group. Fortunately, toxicity from the additional chemotherapy was minimal and mostly included low blood counts, although approximately 30% of patients also had an infectious complication. These investigators concluded that this additional maintenance therapy is an effective and well-tolerated strategy for patients with high-risk rhabdomyosarcoma and proposed to investigate this method in other solid tumor types.

Now additionally, a number of studies presented at the meeting highlighted the importance of physical fitness among childhood cancer survivors. A study from the University of New South Wales in Sydney, Australia collected physical activity data from the parents of childhood cancer survivors and a control population. Fortunately, the parents of survivors reported more physical activity in their children than the control parents with 31% of survivors meeting the recommendations of the American Cancer Society for moderate to vigorous physical activity, which is greater than or equal to 300 minutes of activity per week. However, nearly two-thirds of survivors did not meet the recommended activity level.

Subsequently, a large study from the St. Jude Lifetime Cohort assessed 577 childhood cancer survivors, and 286 healthy community controls. In this study, individuals underwent a series of tests including an echocardiogram and cardiopulmonary exercise testing on a treadmill. Measures of relative peak oxygen uptake or “VO2 max” were obtained to assess exercise capacity. Survivors had a lower VO2 max compared to controls, and this worsened with increasing intensity of previous exposure to cardiotoxic therapies such as anthracyclines and chest radiation. This was also associated with a relatively new measure on echocardiography called global longitudinal strain. In fact, global longitudinal strain, and not the more common measure of ejection fraction, was associated with impaired VO2 max among cancer survivors. Global longitudinal strain may become an important new screening marker for cancer survivors.

And finally, 2 studies from the Childhood Cancer Survivor Study, or CCSS, highlighted the importance of exercise for childhood cancer survivors. The CCSS is a multi-institutional study that uses questionnaires to assess outcomes among a large population of cancer survivors from across North America. Investigators collected data on physical activity, classified as metabolic equivalent tasks, or METs, and expressed as MET-hours per week. Exercise levels were categorized into groups ranging from none or 0 MET-hours per week and increasing incrementally to 3 to 6, 9 to 12, and 15 to 21 MET-hours per week. 3 to 6 MET-hours per week is equivalent to approximately 20 minutes of brisk walking per week, and 15 to 21 MET-hours per week is equivalent to approximately 60 minutes of brisk walking every day for 5 days per week.

And in the first study, investigators showed a decrease in psychological burden among cancer survivors, decreased depression and somatization, and improvements in quality of life and cognitive function among those with increased levels of physical activity. As little as 20 minutes of brisk walking per week was associated with this lower psychological burden. Importantly, in a longitudinal analysis, CCSS investigators showed a decrease in mortality with increasing intensity of physical activity. And looking over eight years, survivors who increased their level of exercise had a 40% reduction in the rate of death compared to those who maintained a low level of exercise. Taken together, these studies presented at the 2018 ASCO Annual Meeting highlight the safety and significant health and psychological benefits of exercise for survivors of childhood cancer.

ASCO: Thank you Dr. Mulrooney.

Next, Dr. Hyman Muss will discuss a study on a tool that can be used to improve communication between older adults with cancer and their doctors. Dr. Muss is a Professor of Medicine at the University Of North Carolina School Of Medicine, and the Director of the Geriatric Oncology Program at the University of North Carolina Lineberger Comprehensive Cancer Center Program. He is also the Cancer.Net Associate Editor for Geriatric Oncology.

Dr. Muss: My name is Hy Muss, and I'm a medical oncologist with a major interest in geriatric oncology. And today I'm going to talk about what I think is 1 of the most exciting studies I've seen in years pertaining to cancer care in older patients, an ASCO presentation by Dr. Supriya Mohile and our colleagues on a large, randomized trial they did, focused on improving communication of older patients with their physician.

So this was a very large PCORI-funded trial in the United States, a federally funded study for patients 70 and older with a whole variety of different cancers. And in this study, what happened were older patients were either randomized to an intervention, which included giving a questionnaire, a geriatric assessment, that asked about function and all types of other issues related to older people, social support etc. And together with that information, there were recommendations for the doctor to talk with the patient about, such as if they had poor social support, maybe get them to a senior facility. Or if they had problems getting meals, set up meals on wheels. Or if they had a physical handicap, get them to physical therapy to try to overcome it. So that was all provided to the doctor.

And the second group of patients just got kind of very little information sent to the doctor. And so what happened in this trial, which was extremely exciting, was that they had 500 patients accrued to this, so this is a huge number of patients. And about half were given the intervention arm and half were just routine care. And it showed that the patients who went through the intervention, and that information was provided to the doctor, had much better communications with the doctor about their illnesses, about their cancer care.

And more importantly, it led to interventions that were very helpful and that probably improved their quality of life and physical well-being, although, these data were not reported in the presentation. And this is really special, because the standard care arm, a lot of things were not discussed, and a lot of things that older patients had may not be related to their cancer but are extremely important for the oncologist to know. And these are things like, "How are you doing at home? Are you able to care for yourself? Do you pay your bills? Do you have good social support? Can you go to the grocery store, etc.? Also, what are your friends like? What are your family like? Do you have people interested in you that take you out, do things?" And frequently, those issues aren't discussed, and they're integral to the care of older people.

So they showed the value of a geriatric assessment, which discovers many more things than the usual questions doctors ask you in 1 or 2 sentences about your function. And more importantly, they improved care, they improved communication, and they led to interventions that make people's lives better, and perhaps, someday a lot longer.

So I thought this was a terrific study. Dr. Mohile and her colleagues broke the glass on showing how important geriatric assessment—where we ask questions about your function, about your health and other things, that are generally not part of a routine history and physical—how important this is to improving care. So I hope you take a look at this at the ASCO site. It's a wonderful trial, and I think it's the beginning of many more similar trials to come. Thank you.

ASCO: Thank you Dr. Muss.

Next, Dr. Michael Thompson will discuss several topics in multiple myeloma that were explored at the 2018 ASCO Annual Meeting, including a discussion on the cost and value of myeloma drugs, a study that compared different doses of a treatment for relapsed refractory multiple myeloma, and several studies that explored ways to personalize myeloma treatment, also known as precision medicine. Dr. Thompson is a hematologist/oncologist, and the Medical Director for the Early-Phase Cancer Research Program and the Oncology Precision Medicine Program at Aurora Health Care in Wisconsin. He is also the Cancer.Net Associate Editor for Multiple Myeloma.

Dr. Thompson: Hello. I'm Mike Thompson, a hematologist/oncologist at Aurora Health Care of Wisconsin. I'm also the Associate Editor for Cancer.Net on myeloma. Today, I'm going to discuss a few myeloma-related areas reported at the ASCO 2018 Annual Meeting. The first is a value debate, which was on Sunday, between Mayo colleagues and friends, Dr. Fonseca and Dr. Rajkumar, who had discussed the question of costs and value in multiple myeloma in this session, Global Myeloma, Health Disparities, and the Cost of Drugs. They disagreed on some issues. But my take-home from their debate was that both the absolute costs of care as well as value, which was utility divided by cost, are important to our entire healthcare system as well as to patients and their families. There was no immediate changes to costs of care after that debate, but I think it's something important that we will all be watching as new drugs are developed in the future.

Another important study was the A.R.R.O.W. study, which was reported on by Dr. Mateos, and was later published with the first author, Dr. Moreau. This was a phase III study of 2 different doses of carfilzomib with dexamethasone in relapsed and refractory myeloma patients. So there was the traditional twice-weekly dose, and there was the once-weekly dose. And the conclusions were that the once-weekly dose with a dose up to 70 milligrams per meter squared improved progression-free survival and overall response rate. And later in the publication, it showed that it improved survival versus the twice-weekly dose at 27 milligrams per meter squared, with a similar side effect profile.

So that is very good news for patients that might get that doublet therapy and have to come into the office less frequently. The caveats with that study are that this dosing was not compared to an intermediate dose of 56 milligrams per meter squared, which has been widely used after that study was published a few years ago. So it's looking at the lowest dose versus the highest dose. And it's also for patients with a performance status of 0 to 1, which means they're doing well. And for many of those patients, we wouldn't use a doublet therapy; we'd use a triplet therapy. So that may limit the applicability in practice, at least, in the United States. And we also don't know that combining this Kd regimen with another myeloma drug is safe or effective, so those studies are ongoing.

And the third topic that was of interest at ASCO 2018 was precision medicine in multiple myeloma. So there were at least 3 parts to this. One is risk stratification. And this has been going on for a while, looking at the cytogenetics and FISH. And the NCCN and Mayo mSMART guidelines give some guidance on how to treat based on risk. Also there was talk about the CAR-T therapies, which may be the most specific or precision type of medicine you can get. And those studies are ongoing but not yet widely available for myeloma, but everyone is very interested in those data. Other therapies were targeted therapies, and there are not as many examples in multiple myeloma as there are in some diseases like lung cancer. But there are some alterations such as BRAF, where BRAF inhibitors are used or can be used in a few patients, in myeloma that have that. And there's great excitement about the BCL-2 inhibitor or venetoclax for t(11;14), which is the most common translocation found in multiple myeloma.

So those are some of the main things I took away from this ASCO meeting. We really need to think about costs and value and the impact it has on our patients. We need to think about trying to dose drugs in ways that are more convenient to patients, and in this case, seemed to be more beneficial. And we have to keep looking ahead to do more things with targeted therapies to see if we can get away from some of the toxicities of some of our chemotherapy agents. Coming up will be more studies over the next year for ASCO 2019, and I look forward to seeing what changes between now and then.

ASCO: Thank you Dr. Thompson.

Finally, Dr. Jyoti Patel will discuss the ongoing research in targeted therapy and precision medicine for lung cancer. Dr. Patel is Professor of Medicine and Director of Thoracic Oncology at the University of Chicago and is the Cancer.Net Associate Editor for lung cancer.

Dr. Patel: Hello. I'm Jyoti Patel. I'm the Director of Thoracic Oncology at the University of Chicago and a long-time ASCO member, and I would like to talk to you today about some of the most important research takeaways from our recent ASCO Annual Meeting. So remember, this is a meeting where about 40,000 cancer care providers come together to discuss and to present the most groundbreaking research and its impact for patients. So this is certainly a meeting that is exciting for all of us and really represents, I think, the best of what's happening in the field.

I think when we look at what's happening with lung cancer—because there's so many people affected with lung cancer in the United States where nearly 200,000 people every year are diagnosed with lung cancer—we can say that we've made significant leaps forward in the past decade, and it's really changed the paradigm in how we treat patients with advanced disease. So it's a disease in which systemic therapy is really the mainstay of therapy because it's not confined to the lung where we may do surgery or radiation, this is really a disease that has spread and is treated as a more chronic condition.

Our efforts at understanding the biology of cancer have really now come back to the bedside, and many of the groundbreaking research trials that were presented really revolved around this idea of personalization of therapy based on biomarkers. Understanding the cancer genome now has a direct impact for our patients. When patients are diagnosed with advanced disease, I think all of these studies point to the fact that we need to have adequate characterization of the tumor. So it's no longer okay to say my patient has non-small cell lung cancer, which is the most common kind of lung cancer, it's really incumbent upon the oncologist, and pathologist, and pulmonologist, and surgeon to come together and further define whether or not there are particular mutations that would serve as good targets for drugs, or whether this is an inflamed tumor and may be best treated with immunotherapy.

When someone's diagnosed with lung cancer, I know it's often difficult for a patient, or family member, to first meet the oncologist and say yes, we have this diagnosis, but I'm waiting for additional tests. But that time that it takes to do this testing—and it's very complex, we look at anywhere from 3, at the very minimum, to almost 1,000 genes at my institution's program—in which we try to match particular drugs with therapies. And the reason we do this is because in about 30 or 40 percent of patients with non-small cell lung cancer that's non-squamous, the most common kind, we're able to find an easily druggable target. So we find EGFR and ALK and ROS1, and so we've got updates on all of those targets at ASCO.

But this year there was really a lot of excitement about a new target called the RET fusion protein and when 2 chromosomes sort of flip-flop and form a protein that causes this cancer to grow. Now this is uncommon, and medically it affects about 1 to 2 percent of patients with lung cancer, but when you look at the enormous burden of lung cancer, that's thousands of patients a year.

What we found was that there's a really selective drug that targets this protein and can shut down the cancer cells and cause deep responses, so almost 80 percent of patients with significant reduction in their tumor and lung responses with an oral tablet that's very well-tolerated. The idea is that we need to absolutely try to do a biopsy, understand if there are multiple markers, and that list continues to grow for which there are druggable targets. And there was a lot of excitement about drugs that target genes such as the MET exon 14 oncogene, or something that's been very elusive for some time, the EGFR exon 20 mutations. These are single sort of base misreads in our DNA that causes cancer to grow, but if 1 patient has this target, and we're able to deliver a drug that causes patients to have nice responses and a return to wellness, I think that's great for all of us.

Often getting the right tissue is tough because sometimes we just don't have enough tissue. And, certainly, we've seen considerable progress with liquid biopsies in recent years, and there's been good concordance between blood-based biopsies as well as tissue, and so our field is rapidly evolving in ways that we can bring the best drugs to the best patients.

We're starting to do this with immunotherapy. There's a protein called PD-L1 which helps us assign appropriate therapy for patients. And so if someone has a high PD-L marker on their tumor, those patients may get immunotherapy alone with an expectation that they would have a nice response and durable disease control with good quality-of-life. So with effort to really characterize tumors, although it can be difficult when someone's first diagnosed to wait to get all these markers right, which is on the order of about 2 to 3 weeks, the downstream effects of characterizing the tissue and getting the right drugs to the right patients are really enormous because we are able to see patients that return to wellness.

Certainly this was an exciting meeting. And I think more and more we're seeing not only medical oncologists, but patients and patient advocates, understanding the importance of biopsies, and an incredible effort by industry, as well, to really make these assays and these tests more accessible to patients, and to make the turnaround times even faster, and to use less tissue to get the right answers. I'm optimistic that we'll continue to see this trend, and there will be more and more drugs that will be optimized for particular patients.

ASCO: Thank you Dr. Patel. If this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play.

To learn more about all of the science presented at the 2018 ASCO Annual Meeting, visit www.cancer.net/ascoannualmeeting. If you have questions about whether new research may affect your care, be sure to talk with your doctor.

Cancer.Net is supported by ASCO’s Conquer Cancer Foundation, which funds breakthrough research for every type of cancer, helping patients everywhere. To help fund Cancer.Net and programs like it, donate at conquer.org/support.

Aug 22 2018

23mins

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Rank #13: Voices on Cancer: Why Cancer in Young Adults Is Different, with Matthew Zachary

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Voices on Cancer is a Cancer.Net Blog series where advocates share their stories and the lessons they have learned about being a cancer advocate. In this Voices on Cancer podcast, young adult cancer survivor Matthew Zachary shares his advocacy story and shares tips to help advocate for young adults with cancer.

Cancer Basics

Apr 25 2017

16mins

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Rank #14: 2019 ASCO Annual Meeting Research Round Up: Soft-Tissue Sarcoma and Melanoma

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ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses.

The 2019 ASCO Annual Meeting, held May 31 to June 4, brought together physicians, researchers, patient advocates, and other health care professionals from around the world to present and discuss the latest research in cancer treatment and patient care. In the annual Research Round Up podcast series, Cancer.Net Associate Editors share their thoughts on the most exciting scientific research to come out of this year’s ASCO Annual Meeting and what it means for patients.

First, Dr. Vicki Keedy will discuss 2 different studies in soft-tissue sarcoma, and explain how the results of these studies have lead to important conversations in the field of sarcoma.

Dr. Keedy is an Assistant Professor of Medicine in the Division of Hematology/Oncology and the Clinical Director of the Sarcoma Program at the Vanderbilt-Ingram Cancer Center at Vanderbilt University Medical Center. She is also the Cancer.Net Associate Editor for Sarcoma.

Dr. Keedy: Hello. My name is Vicky Keedy, and I am a medical oncologist who specializes in the treatment of sarcomas at Vanderbilt University Medical Center. Today, I'm going to talk about 2 important studies discussed at the 2019 ASCO Annual Meeting.

The first study I would like to discuss is called the ANNOUNCE trial. This study looked at whether adding a targeted therapy called olaratumab to the standard treatment, doxorubicin, was better than doxorubicin alone for patients with adult soft tissue sarcomas. In 2016, this combination was approved by the U.S. Food and Drug Administration, or the FDA, based on the results of a smaller phase II trial. This was approved in what is called an Accelerated Approval Program, which requires a larger study to confirm the findings.

The final results presented unfortunately showed the larger phase III trial did not confirm that the combination of olaratumab and doxorubicin was better than doxorubicin alone, meaning there is no benefit to adding olaratumab to doxorubicin. The reasons for the different outcomes between the 2 studies are not completely known and is likely due to a combination of factors. An important finding, however, was that survival in patients with adult sarcomas continues to improve over time. And for patients receiving doxorubicin alone, overall survival was an average of approximately 20 months, showing that doxorubicin is an effective treatment for patients with adult soft tissue sarcomas.

Based on these results, olaratumab will be withdrawn, and no new patients should start on this treatment. For patients already receiving olaratumab for the treatment of their sarcoma, they should have an open discussion with their oncologist about stopping the drug. For patients who their doctors feel they are receiving benefit from olaratumab, there is a program to allow continued access to this drug.

What I think is most important about this trial is the focus it has drawn to clinical research and sarcoma. Because sarcoma is made up of a large number of very different and very rare cancers, advancements in treatments has been relatively slow. The results of this study have led to a larger discussion about how we think about and design trials for patients with sarcomas. It also highlights how important it is for patients to be seen at centers that have trials for their specific type of sarcoma.

Several trials reported at the meeting exemplify how the sarcoma community can successfully complete trials in rare sarcoma and make potentially substantial advancements. One example is the phase II trial of tazemetostat in patients with epithelioid sarcoma. Epithelioid sarcoma is a rare sarcoma sub-type with disappointing results from standard sarcoma treatments. One of the hallmarks of epithelioid sarcoma is the loss of a tumor-suppressor gene called INI1. When INI1 function is lost in a cell, a tumor-enhancer molecule called EZH2 becomes too active. Tazemetostat blocks the action of EZH2. The trial included patients with several types of cancer that have lost some INI1. This trial reported the results of the cohort of patients with epithelioid sarcoma. The results showed 15% of patients had a partial response, meaning their tumors decreased by about a third, with an additional 56% of patients having a minor response or stable disease. Importantly, in many of the patients whose tumors decreased in size, the response lasted for a relatively long time compared to what we typically see with sarcoma-based chemotherapies. The drug was relatively well-tolerated, with the most common side effects of low-grade tiredness, nausea, loss of appetite, and tumor pain. The company who developed tazemetostat has submitted an application to the FDA for consideration of an accelerated approval for patients with epithelioid sarcoma. If approved, this will be the first drug approved specifically for this type of sarcoma.

Again, the study is just 1 example of how we can make substantial improvements for patients with a rare cancer by collaboration amongst the sarcoma community, both nationally and internationally. Although it will not be possible to have a trial for every sarcoma sub-type, when available, it is important for patients with a metastatic sarcoma to go to centers that have trials for their specific disease. With this approach, I believe we will see even more advancements in the future for patients with sarcoma. Thank you very much for your time, and I hope I have more exciting findings to discuss in the future.

ASCO: Thank you, Dr. Keedy.

Next, Dr. Ryan Sullivan will discuss 2 studies in melanoma, including 1 that looked at treatment for melanoma that has spread to the brain, and 1 that is a long-term follow-up on targeted therapy for melanoma with a BRAF mutation.  Dr. Sullivan is a medical oncologist and Attending Physician in the Division of Hematology/Oncology at Massachusetts General Hospital. He is also the Cancer.Net Associate Editor for Melanoma and Skin Cancer.

Dr. Sullivan: Hello. My name is Ryan Sullivan. I'm the Associate Director of the Melanoma Program at the Mass General Hospital Cancer Center in Boston, Massachusetts. Today I'm going to discuss research that was presented at the 2019 ASCO Annual Meeting in the Melanoma Program. There are 2 presentations that I'm going to highlight.

The first is a presentation by Dr. Hussein Tawbi from MD Anderson in Houston, Texas, who presented a follow-up of the safety and effectiveness of a combination of 2 treatments called nivolumab and ipilimumab given together in patients with melanoma who had brain metastases. This trial is also known as the CheckMate 204 study and initially, was presented in 2017 at the ASCO Annual Meeting and was subsequently published in 2018 in 1 of our prestigious journals called the New England Journal of Medicine.

This is an important study because it truly is the largest and most relevant clinical data that we have in how to most effectively treat patients with melanoma who have brain metastases. Brain metastases, unfortunately, are very common scenario for patients with metastatic melanoma. While the majority of patients probably do not develop brain metastases a significant minority do, and brain metastases can certainly complicate the treatment of patients with melanoma. Furthermore, they are also commonly and traditionally very commonly then a cause of death for patients with metastatic melanoma.

The CheckMate 204 trial built upon a number of emerging clinical trials that were showing that some of the newer treatments for melanoma, specifically drugs called immune checkpoint inhibitors which are therapies that alter the way that the immune system interacts with the cancer, have been increasingly effective in patients with metastatic melanoma, and furthermore have actually been moved forward into earlier stages, for example, stage 3 melanoma. And a logical question was whether or not these treatments would be effective in patients with brain metastases.

A common problem with therapies in patients with brain metastases is they may not get into the brain or the tumor to effectively treat that tumor and that was specifically a concern with these types of therapies. However approximately, it was almost 10 years ago when the trial was run and probably 8 years ago when it was published was the trial of ipilimumab in patients with brain metastases. Which the summary of it was that that drug worked about as well in patients who had disease in the brain particularly if that disease was asymptomatic and didn't require treatment for symptoms—it worked about as well in patients who were in that situation whereas patients who didn't have brain metastases but were treated with that medicine and about 20% of patients had long-term control of disease.

Moving forward, the last few years there's been clinical trials that have been published and presented about PD-1 blocking drugs called pembrolizumab and nivolumab which seemed to work a little less well in patients who have disease in the brain, and specifically these drugs probably, in patients who present with metastatic melanoma and are treated and don't have brain metastases, probably about 40 to 45 percent of patients have disease control in response and maybe a third of patients have control that's long-standing. In patients who have disease in the brain, it appears that that number is about 20 or 25 percent with response and durable control of disease, so effective, but not as effective in patients who do not have brain metastases.

So one logical question with emerging data about the combination of ipilimumab plus nivolumab, so ipilimumab plus a PD-1 blocking drug, was whether or not there would be a higher effectiveness. In patients without brain metastases, there's a clear improvement in response rate and maybe a delay in progression of disease and maybe even a slightly better overall outcome in terms of living longer for that combination, but that combination has side effects and those side effects can limit the effectiveness of the treatment.

So it wasn't clear whether or not combining these drugs would be the best scenario for patients with brain metastases. However, this clinical trial, the CheckMate 204 study, looked to study just that. The initial data that had been presented and published was based on 101 patients who were treated. These patients did not have any symptoms of brain metastases but were identified to have these brain metastases on imaging that was done probably just prior to starting therapy for recurrent and/or newly diagnosed metastatic disease. And amazingly over 50% of patients had responses to this combination on this trial, so of the 101 patients, 55 had a response and 59 had control of disease. And perhaps more amazingly, over time, the control of disease rate, which we call progression-free survival which basically just measures whether or not patients are alive and that their disease hasn't progressed, remained pretty stable at about 60%. So 60% of patients at 6 and 12 months had disease that hadn't progressed in the population of patients that previously had very bad outcomes. And that was really better than anything we've ever seen in these patients.

More importantly, the great majority of patients were alive. So almost over 90% of patients at 6 months, over 80% at 12 months, about 75% of patients at 18 months, and it seemed like that was pretty stable thereafter. And so a therapy that had shown effectiveness in patients with melanoma who don't have brain metastases seem to be even more effective in patients who did have brain metastases, at least when you compare that to outcomes that had previously been presented or published with just a single drug of nivolumab or the similar drug called pembrolizumab. So that data that was previously presented and published really set the new standard of care for patients who were diagnosed with metastatic melanoma who were unfortunate enough to have brain metastases, for us as providers who are treating these patients to say, "You need to be on this combination."

At the ASCO meeting, in addition to sort of the update that I just provided, they also presented the data from the cohort B. The second part of this study was in patients who actually had symptoms, and in those patients with symptoms they could be on medicines called steroids. Steroids often will reduce swelling in the brain around a metastasis and can make the symptoms better, however, the challenge with that is these medicines tend to be suppressive of the immune system and so they theoretically could counteract immune therapy like ipilimumab and nivolumab.

In any event, there were 18 patients that were treated on this part of the study. 4 of those 18 patients had responses, so that was over 20%. And importantly, of those patients who responded, 3 of the 4 were not on steroids. That baseline, again, suggesting that potentially patients who are on steroids may have worse outcomes than patients who aren't on steroids, may do a bit better. There's certainly going to be a bit longer follow-up needed to truly understand how effective this approach is in patients who have symptoms and who may be on some steroids. But the bottom line is it's clear that patients who are having symptoms, this is still the best regimen for patients with metastatic melanoma with disease in the brain and that it's possible to have responses even in the situation where those symptoms require patients to be on steroids. And so this is really important information for the field. And again, though it doesn't change the standard of care—our standard of care changed a year-and-a-half or two years ago with the initial presentation of this data, but it solidifies the standard of care and expands it a bit out to patients who also may have some symptoms and/or who may be on steroids and that this is an approach that's possible.

The second study that I wanted to talk about was a presentation. It was the first presentation of very long-term follow-up on BRAF-targeted therapy. So BRAF-targeted therapy for patients with melanoma is only appropriate for about the 40 or 50 percent of patients who have a BRAF mutation that's identified in their tumor. BRAF is a gene that leads to a protein that ends up being a very important part of the signaling pathway that leads to tumor growth and metastasis and evasion of the immune system. And as I stated, about 40 or 50 percent of patients who have melanoma will have an identifiable mutation in BRAF and that BRAF mutation drives tumor growth in those patients.

There are now three combinations of inhibitors that block BRAF and its subsequent signaling to a protein called MEK. And so our standard BRAF-targeted therapy is a BRAF inhibitor and a MEK inhibitor. There are three combinations: dabrafenib plus trametinib, vemurafenib plus cobimetinib, encorafenib plus binimetinib. So there are 3 regimens that are FDA approved for patients with BRAF mutant melanoma that's metastatic or unresectable.

Now, we know that these drugs are very effective. About 70% of patients have significant regression of tumors, and we know that when we compare these to single BRAF inhibitor treatment that combination is better, that patients live longer, have more responses, are less likely to have their disease progress. We know that BRAF inhibition versus chemotherapy is better on all those same parameters. And so what we don't know, however, is whether BRAF-targeted therapy’s better than immune therapy, and the purpose of the study I'm going to describe doesn't address that. There are a couple of trials that are still being enrolled to across the world that are answering that question, but we don't have that data to make any definitive statements about what's the best first therapy for a patient with BRAF mutated melanoma. However, we haven't had very long-term data with these combinations.

So this presentation by Dr. Paul Nathan was a combination of patients that were enrolled to either the COMBI-d study which compared dabrafenib, trametinib versus dabrafenib and the COMBI-v study which is dabrafenib, trametinib versus dabrafenib. And the data that was generated was looking at the 211 patients who got dabrafenib and trametinib in the COMBI-d and the 352 patients that got dabrafenib, trametinib in the COMBI-v study, and they just pooled all of that data together and followed to see how well those patients did.

The 3-year data was presented and published a few years back. This was the 5-year data, and I think the most important points are that about 20% of patients are still alive and without progression at 5 years. BRAF-targeted therapy was thought to be something that would be a temporary help and that wouldn't lead to durable benefit, but in fact, it seems like we're seeing durable benefit in these patients and more importantly, over 30% of patients were alive at 5 years. That number being 34%.

When the investigators broke that down, we know that a protein that we can measure in the blood called LDH is associated with poor outcomes, and we know that patients who have a normal LDH tend to do better with these types of therapies. And in fact, over 30% of patients who had a normal LDH and limited number of metastatic sites were alive and progression-free at 5 years. And when you looked at that same bit of data with regards to whether people were alive or not, the great majority, 55%, were still alive at 5 years. So this is proof that some patients can have long-term benefit and disease control with BRAF-targeted therapy who are started on BRAF-targeted therapy as their first treatment for metastatic melanoma, and that if you select patients just by very easily and readily available criteria, like this blood LDH measure and how many sites the melanoma has traveled to, that you can identify a population of patients where the majority will be alive at five years.

Now, we have more work to do. We still need to learn a little bit more about who those 30% of patients are that may have long term disease control in addition to the LDH measure, in addition to the number of metastatic sites. And we and others are working on trying to develop better tests to identify who those people are so that when we have a patient with metastatic BRAF mutated melanoma in front of us we can best offer them the option of BRAF-targeted therapy or immunotherapy and be smarter about making that decision. But I think that this is really an important piece of information because it does prove the concept that long-term control with disease is possible with a therapy that 10 years ago we didn't think long-term disease control was going to be possible. And so it's really exciting data to finally see it. We obviously have a lot more work to do. It's not acceptable to only have 30% of patients alive five years later. We need to get that number to 100% and along the way get it to 50 and then 60, and 70, and 80 percent, etc. But the fact that this data demonstrates that long-term control is possible with these therapies really does make us feel better about offering this to some patients in the front-line setting, and more importantly, inspires us to do additional research to truly figure out who those patients will be.

And with that, I'd like to thank you for your attention today, and it's been a pleasure discussing these 2 presentations at the 2019 ASCO Annual Meeting. Thanks.

ASCO: Thank you Dr. Sullivan.

Learn more about these topics and other research presented at the 2019 ASCO Annual Meeting at www.cancer.net.

If this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play. And stay tuned for additional Research Round Up podcasts coming later this summer.

Cancer.Net is supported by Conquer Cancer, the ASCO Foundation, which funds breakthrough research for every type of cancer, helping patients everywhere. To help fund Cancer.Net and programs like it, donate at conquer.org/support.

Jul 18 2019

21mins

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Rank #15: HPV and Cancer, with Howard Bailey, MD

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In today’s podcast, Dr. Howard Bailey will discuss human papillomavirus, or HPV, and explain why it’s associated with certain types of cancer. He also discusses HPV vaccines, and how they can help lower the risk of these cancers. 

Cancer Screening and Prevention

Dec 01 2016

13mins

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Rank #16: Food Anxiety and Cancer, with Julie Lanford, MPH, RD, CSO, LDN and Debra L. Benfield, MEd, RDN, LDN, RYT

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ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses.

In this podcast, registered dietitians Julie Lanford and Debra Benfield will discuss food anxiety before, during, and after cancer treatment, including potential causes and healthy ways to address food anxiety at any stage of treatment. Julie Lanford is a registered dietitian with Cancer Services in Winston-Salem, North Carolina. Debra Benfield is a Master’s Level Nutritionist as well as a Registered Dietitian Nutritionist and Licensed Dietitian Nutritionist in Winston-Salem, North Carolina.

ASCO would like to thank Ms. Lanford and Ms. Benfield for discussing this topic.

Julie Lanford: Hello. I'm Julie, and I have been a registered dietitian for 13 years, and almost all of that time has been spent helping people facing cancer. Currently, I work for Cancer Services, a community non-profit in Winston-Salem, North Carolina. I have a master's degree in Public Health. And I'm a board-certified specialist in oncology nutrition, as well as being a registered dietitian. And I write cancerdietician.com. And today, I am here with my friend and colleague, Debra Benfield.

Debra Benfield: Hello. Thank you for having me. So just a few sentences about me, my name is Debra Benfield. And I am also a registered dietitian. I have been in practice about 30 years. And most of my time has been working with folks who have a complicated relationship with food and their bodies, all sorts of disordered eating, as well as actual eating disorders. And I'm also a yoga teacher, so I bring in somatic practices or practices that include the body and breath, along with helping people normalize their relationship with food. So that's what we'll be talking about today, I think.

Julie Lanford: That's right. So our topic today is food anxiety, which is an interesting topic, I think. Having worked in oncology, it's sort of something that, I guess, maybe I refer to on occasion. But the interesting thing is that we don't really have a definition for it in a clinical kind of environment. And so having Debra here, with so many years of experience working with this sort of complicated thing, I wanted to get her thoughts, in terms of, how do you define food anxiety? Or what does that mean?

Debra Benfield: So when you first asked me about this, we did talk about the fact that it is a term that doesn't exist in the world. So I think we've created a lot of anxiety around food. I think our current cultural conversation around food is full of fear and anxiety and very dogmatic belief systems that create more emotion. So the actual definition of anxiety, as I looked it up, is "distress or uneasiness of mind caused by fear." And I think if you apply that to food, it makes perfect sense. That is what I think I work with a lot in my practice, is a sense of distress or uneasiness of the mind, that is actually caused by fear around food choice, which is a very uncomfortable reality. Because we all know we need to eat many times, every day. We can talk about what that feels like. But that's a pretty hard place to be in the world. Because food, in my opinion, is something that brings pleasure into our lives and gives us a sense of energy. And we're going to talk a little bit more about the mental health aspect of how we feed ourselves to nourish ourselves. So that's what I think now exists, as far as food anxiety.

Julie Lanford: Great. So in an oncology setting, there are sort of 2 areas that I see, maybe 2 groups—I  don't know what you would call it—regarding food anxiety around time of diagnosis or during treatment or after treatment. So the 2 types, for lack of a better term—1 is when cancer and its treatments cause difficulty with eating or digestion, and therefore that makes mealtime or post mealtime stressful. So some examples on that would be, if somebody has had part of their GI tract removed—so part of their colon—or when they have an ostomy bag, or they just have a change in their bowel habits, where whenever they eat, they have to be located close to a bathroom. Or they have side effects from certain foods that cause them to not want to be in public or that make them afraid that the food they're eating is going to cause a problem. Or if they're having nausea from their cancer treatment, they're afraid to eat because they don't want to have an adverse effect that makes them feel bad.

And so that's 1 challenge that I think people have, especially around having to be located proximate to a bathroom. I know that that keeps people—either they have to time their meals a certain way, based on what kind of activities they want to do for the day, or they cannot choose their favorite activities because of their digestive issues. So that's 1 area.

And then the other sort of group of cancer survivors that I work with, who have, I think, challenges with food anxiety, is around the idea that they're afraid that something they've eaten has maybe influenced the growth of their cancer. So that there are certain foods that are toxic that caused cancer to grow, or that there are certain foods that they absolutely must include enough of in order to "fight off the cancer." And so those are 2 areas. And Deborah has also worked with several of our clients here at Cancer Services, and I think, if you want to give some examples of people that you've worked with in the cancer groups and some of their anxieties.

Debra Benfield: Sure. One of the things that I think about is a very striking kind of guilt that people start to associate—in my opinion, it's much more focused around sugar, right now, as far as what people are hearing from sources I'm not so sure about, on the Internet, that actually tell our folks that sugar is causing or contributing to their cancer. And many people start to, maybe without conscious awareness, start to feel guilty because they know that they've enjoyed sugar in their lives. And they feel like they have actually caused their cancer. So I try to help people realize that that's probably not a rational thought pattern, that that's probably a fear-based irrational thought, and does give folks something to focus on, something to feel like they might be able to control, knowing that they don't have as much control over their diagnosis.

But they do kind of have a false fear-based belief that they can actually have a sense of control of their lives if they just eat a certain way. And, again, it may not be a conscious thought. It could be just something that you start to feel, that you need to white knuckle and control this aspect of your life, when other things feel like they're swirling out of control. So I try to help people realize that they did not cause their cancer, that the guilt that they feel with food may be even more unhealthy than the actual food itself, that the actual guilt and anxiety that arises is, in my opinion, more unhealthy. Because I look at the whole person. I think mental health is a very important aspect of a person's life. So to try to help people feel less guilty and more a sense of knowing that they can create ease with a more moderate way of thinking about how they make food choices and nourish themselves. So I try to ease up on the rules and the dogmatic rigidity that people start to have, which the rigidity itself can create its own disorder.

Julie Lanford: Right. And I think for a lot of the people that I work with, both online and in real life, sometimes, their fear around food pushes them to the point of restriction in a way that is not healthy, nutritionally. So their intake of certain nutrients is inadequate because their food restrictions are so many. So someone who thinks that sugar is a problem, that it causes cancer, and somehow they start limiting all types of sugar, including healthy carbohydrates. If they completely eliminate all grains and all fruits, which I've had some people come into me having done that, I am very concerned about their ability to adequately nourish their bodies, especially during treatment, recovering from treatment, those types of things. So sometimes, it really does come to that point where their concern and their food anxiety is so strong, that it changes their behaviors in a way that is detrimental to their health, which is exactly the opposite of what they're trying to go for.

Debra Benfield: Right. Right. It presents its own problem.

Julie Lanford: Yes. And we can't help them nourish themselves if they can't get past some of these emotional fears around certain foods. So interestingly, I think that there are several things that come into play, so like you were mentioning, wanting control, especially earlier on in diagnosis. I've had people call me on the phone, and basically, they've been diagnosed, but their treatment regimen isn't figured out yet. And that seems to be a time of sort of crisis, where they want to do whatever they can. And so they're grasping on to the food thing because they don't have any other answers at that point. And it seems to be a time that they're very anxious and they drastically change some of their eating habits, and also have incorporated a lot of guilt.

I think that well-intentioned advice-givers, which we all have those in our lives, but it seems like upon diagnosis of cancer, the advice-givers come out of the woodwork. And they're sending you emails and telling you all kinds of, who knows, legitimate and not-legitimate information that they've heard or read, that oftentimes layers on this guilt, foods to eat or not eat.

They seek out information on the internet, from documentaries, from other cancer survivors, who maybe are giving not so evidence-based nutrition advice.

I think those are some examples, but also caregivers really want to help out, and especially in the case of people who don't feel like eating, caregivers can, I think, add more anxiety to the table, when they want their loved one to eat so badly that they almost guilt them into eating when they just don't feel like it. And that's a whole ‘nother level of, "Well if you don't eat what I made for you, what does that say about our relationship," and all of that. So those are a couple of other things that I don't know what your thoughts are about that.

Debra Benfield: I agree 100%. And as you were talking, I was thinking about relationship to body, in general. I mean, in my opinion, a cancer diagnosis can many times feel like a traumatic interruption to a person's life, as well as if there is a surgery process, or maybe even going through some of the actual treatment protocols, in the experience itself, there can be a sense of anxiety-provoking trauma.

And that, in itself, affects the body's ability to digest. I mean, their digestion is affected by stress and anxiety. So things start to take on their own dynamic. And I think we're going to talk a little bit more, in just a minute, about what to do about that. But I think, considering that your fear can affect your ability to digest your food, your belief about the food itself can create anxiety that can make you even have symptoms, that we've talked a little bit about, about having to be close to a restroom. So trying to drop away from all of the fear and anxiety is not such an easy thing to do. There are layers of complication and also just body itself.

I work, in my practice, and when I come over and work with clients who have a cancer diagnosis here, there's a complicated relationship with body itself, so body shape, body form, thinking that there needs to be weight management at this particular time is a whole ‘nother dynamic. So that the people can feel more comfortable in their bodies, or maybe have the body that they used to have, a relationship with their body that they had before diagnosis. So you can see how this just starts to become more and more complicated through our folks.

Julie Lanford: You know, as healthcare providers, and during treatment, a lot of times, we're pushing people to get enough nutrients in, to keep their weight up, and to not lose too much weight. Because that can adversely affect outcomes. And then sometimes, those same people then create behaviors, I guess, around like, "You've got to eat enough." And then, at some point, you can stop doing that. It's like you're constantly having to learn and adjust to what your body's needs are at whatever that time is. And then, there's other people who are told during treatment, "Well, we're concerned that you have too much weight.” And maybe a physician has told them they need to lose weight. And that, after facing a cancer diagnosis, having your doctor push you around losing weight, it just can add so many other things on top. And so I think that's another area where somebody takes on some of these thoughts and behaviors that pushes them towards anxiety.

Debra Benfield: And I'm sitting here also remembering so many stories around taste changes. And the more I talk about this, the more I feel great empathy for somebody going through this. Because there's so much going on at one time around what could be, and I would like for it to be, a much less complicated, more simple part of life, when life already feels complicated enough.

Julie Lanford: It should be less complicated.

Debra Benfield: It would be nice.

Julie Lanford: And any way we can lower the anxiety. So I think that actually is a good transition to some of our practical recommendations around this. Because our listeners could be from all kinds of different places. But I'm certain that for pretty much everyone, there is something that we've talked about that's resonated.

So some of the practical tips that we've thought through, for the people who are dealing with those physical side effects of treatment, whether they need to be near a bathroom, whether they are having bowel movements multiple times a day, or maybe on the opposite side, they're having constipation that's causing them debilitating pain, I think the first thing for those people is to maintain a constant conversation with their medical team about how they can manage it, so that they can do the things that they really want to do in life. So it may be keeping a food log and figuring out trigger foods and avoiding those around times that they have activities. It might be using medical management, so for people who have multiple bowel movements a day, they might need to use Imodium. And their medical team can help them come up with some kind of regimen.The same thing if someone's on pain medication, and constipation is causing them issues. They need to constantly be in contact with their medical team to figure out what is the solution to deal with this.

And then, for the people who have caregivers, early on in my career working with cancer patients, I came up with sort of this guideline for caregivers who are feeding loved ones. And I encouraged caregivers to know that you are loving your person by preparing them food and offering it to them. And whether that person eats the food or not, you need to tell yourself you're doing a good job. So the caregiver's job is basically to, maybe remind the person it's been a couple of hours and maybe they want a snack, and is there something they can give them. They can prepare the foods that they think will be well received. But it is the person facing cancer's job to decide what and how much they're actually going to be able to put in their mouth and swallow, and to try to separate that behavior of actually eating from impacting their love relationship.

Debra Benfield: I think there is an anxiety, a feeling of pressure around eating or not, is its own anxiety. I mean, choosing to eat and what you're going to eat and how much you're going to eat is a personal choice. So when somebody intrudes into that, however well-intended, there tends to be an emotional reaction. And that's uncomfortable. And I think it's unnecessary.

Julie Lanford: Yeah. And we don't want to ruin marriage relationship while we're at it, or a friend--

Debra Benfield: Right. Any other time-- right.

Julie Lanford: --Friends who are trying to help feed you. So that's my caregiver and care receiver tip.

Tips on how to deal with unwanted advice. So I actually have several talking points that I give my patients around how to deal with it. But I think the most important one that you can always remember is to have 1 easy statement that says, "Oh. Thanks for your concern. I'm working really closely with my medical team. I'll bring this by them." And then change the subject. So that's kind of—you can receive their intention to give you assistance without internalizing their advice. So kind of let it come 1 ear and out the other and send it on its way.

Debra Benfield: Nice.

Julie Lanford: Tips on how to evaluate nutrition information. So I started writing cancerdietitian.com in 2007 because I had so many clients coming in asking questions and not knowing where to turn to get legitimate information. I will say, most information that you read on the internet is not true. And just because someone said it or wrote it or put it on Facebook or Instagram or wherever, does not make it true. And sometimes, you need to control the flow of information. So be very cautious about where you're going, and also know kind of who you trust. So, hopefully, a lot of people are trusting their care providers. And I usually say, if you stick to things like university or legitimate treatment websites, then you're probably going to be good. But I would stay away from celebrity advice, Netflix documentary advice, and then people who don't have any credentials whatsoever. Health coaches, nutrition coaches don't count as legitimate credentials for giving nutrition advice.

Debra Benfield: And I trust you, Julie, completely.

Julie Lanford: So do you have other, for your clients with eating disorders or disordered eating—how do you help them with their seeking out of nutrition information?

Debra Benfield: Yes. It's loaded. There are just thousands, literally thousands, of books, and not to mention internet accounts and Facebook accounts and Instagram accounts that are focused on weight management. So I highly recommend not following accounts that are about that. My favorite resource is a book called Intuitive Eating. And I don't know if that would be of interest. But I think it's very helpful, when it comes to trying not to fall for actual belief systems around food that lend themselves to feeling like there's a list of foods that are good and a list of foods that are bad. Because those kinds of lists will create a dynamic within you, as the reader, where you feel like you are being bad and being good when you eat those foods. And then maybe even that you are good or you are bad, which is where shame lives. And I don't think you want any additional shame or guilt.

So if you see an “Eat This, Not That” list, I would see that as a red flag. And I'm all about finding a way to listen to your own instincts around what helps you feel good. How do you feel when you eat certain foods and tune into what your body is letting you know about what feels supportive and nourishing versus making me feel sluggish or if you pay attention—and Julie mentioned keeping a log—you'll notice that certain foods really do help you feel your best, and certain foods don't contribute to that. So I would trust that you listen to your body way more than the food list. Yeah.

Julie Lanford: Yeah. It's funny because I developed an email program. And what people wanted was, what to avoid, what to eat. And so I was like, "All right. I should call it that because that's what people want." And then I realized, "Okay. I'm going to call it that, but that's not really—I don't have a food list." So what we went with was, “what things to eat most of the time,” because I don't believe you have to avoid any particular foods. It's kind of more about how you're feeling, and what your body kind of needs at that time. So it's funny to balance that, what you think you want and actually what you really need.

Debra Benfield: The way I think about that is like, head down and gut up. You kind of have to listen to your body, and there is just this information that you know that is more helpful for you. And it can't be true all the time. I mean, you get to have treats just because there are certain foods that actually just help you feel happy, like maybe childhood favorites. Yeah.

Julie Lanford: Yeah. Your soul foods.

Debra Benfield: It's a good way to put it. Yeah.

Julie Lanford: Okay. I think the last thing kind of on our to-do list is how to know when you need professional help. Because, at least what I see with my patients coming in, is that sometimes they've actually had a kind of a significant amount of disordered eating behaviors prior to a cancer diagnosis. And possibly, the cancer diagnosis has just exacerbated the problem. Or it could be somebody who had a perfectly healthy relationship with food, they get a cancer diagnosis. They have treatment. Their body is reacting very differently to the foods that they historically had really enjoyed before. And now, all of a sudden, everything's turned upside down. And I think, in those cases, there is some pretty clear times when you will want to seek out a dietitian or a therapist, who can help you work through those things. So what kinds of kind of red flags or things do you notice would be something you'd suggest somebody to seek out help.

Debra Benfield: So disordered eating and eating disorders is based in thought patterns that can contribute to behaviors. And if you find that your thoughts are highly rigid, that, in my opinion, is something you may want to seek help with. If you can't just be social. I mean, I know we've talked about how complicated that can be. But if you feel like you have to take your own food to social occasions—and I'm sure there are events where that's necessary, at some point. But if that's the way you always, literally always feel, like you can't just trust food that other people prepare, then you may have crossed over into a lot more rigidity than is healthy for you.

Julie Lanford: And not because you're allergic to the food, but because you think that it's toxic to your body.

Debra Benfield: Right. Yeah. So I would consider rigidity of thought and behavior to be one major area that you want. I would encourage flexibility as an antidote, to try to let yourself relax and try things that you may feel are on some sort of list that is bad, just to see if you can be flexible and encourage more comfort. If you remember that the definition of anxiety is distress in your mind, what brings you more ease? So anything that creates rigidity of behavior and thought pattern. And then the other piece, I think is guilt. If guilt becomes debilitating to the point that you just feel like you're being bad way too often, so that you feel sad and maybe even depressed, I think that if you've noticed that your anxiety and depression is higher, then I think you need some support.

Julie Lanford: And probably a large majority of people who've faced a cancer diagnosis, I think would benefit from counseling and helping to cope with everything that's going on. I think something else that comes to mind is, if you're in a situation where, when it's time to eat, if you can't identify something that you can nourish your body with, and so then you sort of go without or have something that's not really a complete full meal, that would be another red flag. Because there's always a good choice. There is always a best choice. No matter what situation you're in, you shouldn't feel like you have to go without.

Debra Benfield: Right. If you've worked yourself into a true corner, where your list of foods that you can eat is so short that you feel like you eat the same thing over and over and over and over again. That's problematic.

I wanted to say a couple of things about the fact that not eating enough, and not eating enough for your body's needs, or eating frequently enough, can in itself cause anxiety. If the human body is under-nourished, the brain is the organ that's affected first, and anxiety goes up. So just the process of not eating frequently enough and enough for you, can in itself cause anxiety and some sadness.

Julie Lanford: So I think, in summary, we both want to feel like we leave our listeners with less anxiety and more hope and positive feelings. So my take home for all of my clients is to remember that staying well-nourished does improve your body's ability to tolerate and respond to treatment. And food is neither toxic or magical. And so, if you feel like your stress regarding food and nutrition is overwhelming, then I wouldn't be shy to seek out for help. But I'd also like to just remind you that there is no toxic food. There's no magical food. And I want you to have less anxiety around food choices.

So Deborah, it's been really awesome sharing this time--

Debra Benfield: Thank you. Me too.

Julie Lanford: --and your expertise. But if you had one take-home message that you would share with listeners, what would it be?

Debra Benfield: Mine is very short and sweet. And it's kind of a summary of what Julie just said, and that is, you can't mess this up. You can't mess this up. It's just one meal, one snack at a time. Continue to try to listen to your body. You can't mess it up.

Julie Lanford: So there you go. That's awesome. Thank you so much for being here.

Debra Benfield: Yeah. Thank you. Thanks for inviting me.

Julie Lanford: Yeah.

Debra Benfield: Obviously, we could keep talking.

Julie Lanford: Forever.

Debra Benfield: Yes. Lots to say.

Julie Lanford: All right. Take care.

Debra Benfield: Bye.

ASCO: Thank you, Ms. Lanford and Ms. Benfield. Find more podcasts about nutrition and cancer at www.cancer.net. And if this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play.

This Cancer.Net podcast is part of the ASCO Podcast Network, a collection of 9 programs covering a range of educational and scientific content offering insight into the world of cancer care. You can find all 9 shows, including this one, at podcast.asco.org.

Cancer.Net is supported by Conquer Cancer, the ASCO Foundation, which funds breakthrough research for every type of cancer, helping patients everywhere. To help fund Cancer.Net and programs like it, donate at conquer.org/support.

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