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ASCO Daily News

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The ASCO Daily News Podcast features oncologists discussing the latest research and therapies in their areas of expertise.

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The ASCO Daily News Podcast features oncologists discussing the latest research and therapies in their areas of expertise.

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23 Ratings
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Love the new host!

By ?.... - Jan 18 2018
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Great resource for a more intimate understanding of cancer and the evolving treatments

iTunes Ratings

23 Ratings
Average Ratings
18
3
1
1
0

Love the new host!

By ?.... - Jan 18 2018
Read more
Great resource for a more intimate understanding of cancer and the evolving treatments
Cover image of ASCO Daily News

ASCO Daily News

Latest release on Feb 21, 2020

The Best Episodes Ranked Using User Listens

Updated by OwlTail 6 days ago

Rank #1: Immunotherapy: ASCO 2017

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Roy S. Herbst, MD, PhD, provides updates on immunotherapy for cancer treatment.

May 24 2017

16mins

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Rank #2: Triple-Negative Breast Cancer: Dr. Heather L. McArthur

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Heather L. McArthur, MD, MPH, of Cedars Sinai Medical Center, discusses advances in the treatment landscape for patients with triple-negative breast cancer.

May 30 2018

15mins

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Rank #3: ASCO18 Takeaways: Dr. John Sweetenham

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Editor-in-Chief of the ASCO Daily News John Sweetenham, MD, FRCP, FASCO, discusses the practice-changing science presented at the 2018 ASCO Annual Meeting.

Jun 04 2018

7mins

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Rank #4: Dr. Nina Shah Highlights Key Poster Presentations in Immuno-Oncology from ASCO's Annual Meeting

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Dr. Nina Shah Highlights Key Poster Presentations in Immuno-Oncology from ASCO's Annual Meeting.

Jun 10 2019

4mins

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Rank #5: Lung Cancer: ASCO 2017

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Nathan A. Pennell, MD, PhD, discusses notable lung cancer abstracts from the 2017 ASCO Annual Meeting.

May 30 2017

20mins

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Rank #6: Dr. Benjamin Maughan Highlights Key Poster Presentations in GU Cancer from ASCO's Annual Meeting

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Welcome to the ASCO Daily News podcast. I'm Lauren Davis. And joining me today is Dr. Benjamin Maughan, an assistant professor in the division of medical oncology at Huntsman Cancer Institute. Dr. Maughan, welcome to the podcast. Well, thank you. It's a pleasure to be on, Lauren. It's always great to visit with you. We're glad you're here. Today, we're talking about stand out poster presentations from the ASCO annual meeting that concluded Tuesday for oncologists who are interested in prostate cancer. What did you find most interesting? You know, Lauren, there were so many great things. For oncologists interested in GU, this is such a great time. I mean, there's so much research going on. There were some wonderful plenary sessions, amazing oral abstracts and poster discussion sessions as well. But it's always riveting for me to go through the posters themselves that don't get the big splash news that a lot of those late breaking abstracts do, because there's so much great research happening that you just can't put it all in oral sessions. So there's so much great research that you can gain by going through the posters as well as well as being able to meet one on one with the principal investigators of that research. So there's quite a few things. I mean, just to start off with thinking about prostate cancer, there's a lot going on in prostate cancer research today. You know, one of the things that I found most fascinating was actually way in the back towards the end of the prostate cancer posters. Now forgive me. I wrote down the name to try and not get it wrong, but I'll probably mispronounce it. So apologies if you're listening. But Dr. Linda Huynh, I believe is how you pronounce it. The abstract number is 5085 from UC Irvine I believe is where this person works. But they were evaluating this concept of giving testosterone replacement therapy to patients with localized prostate cancer that have had a prostatectomy. So they evaluated these patients retrospectively. But they were treated, obviously, prospectively and the data was collected prospectively. But they identified 152 patients that had received a prostatectomy for localized prostate cancer and then, shortly after that, received testosterone replacement therapy to treat their hypogonadal symptoms. So then they case controlled this against 419 patients that had a prostatectomy for localized disease and did not receive testosterone replacement therapy. The primary endpoint that they were evaluating in this retrospective study was the time to PSA relapse. So interestingly, seven of the patients that had testosterone replacement therapy ultimately went on to experience biochemical relapse, so about 4% or 5% of the patients. Of those that had a prostatectomy and no testosterone replacement therapy, 39 of those patients had a PSA relapse, so about 9% or 10%. So it's a retrospective study. There's a lot of inherent biases in that. But surprisingly, the trend favored testosterone replacement therapy. Now I'm not here to say testosterone replacement therapy will help as an adjuvant treatment to protect these patients from a PSA relapse. But it's really striking and surprising. Because right now, the dogma is if you've ever had prostate cancer, then you should be very cautious or not at all ever receive testosterone replacement therapy. And they're showing that it possibly could be very safe and have a huge impact on these patients' quality of life. So that was fascinating to me. Along those lines with trying to find improvements in quality of life, there is another really interesting study that's sort of paving the way for a new paradigm of how we think about and treat prostate cancer. So Dr. Emmanuel Antonarakis from Johns Hopkins, many people may know his name as someone along with Dr. Jun Liu that helped bring to the forefront this whole new science of antigen receptor spliced variants. It sort of went off on a whole new vein of research here. I'm sorry. His abstract number is 5045, and he was evaluating in a pilot phase II study an androgen deprivation therapy sparing approach. So for the most part, as we all know, as soon as patients have relapse disease and they start systemic therapy, the bedrock or foundation of that treatment is testosterone suppression with androgen deprivation therapy. There's all kinds of side effects that are attended with that, both things that just are bothersome to the patient but significantly impacting their quality of life with hot flashes and fatigue and mental impairment and cloudiness, all the way to those asymptomatic problems that are very real and problematic, worsening of osteopenia and osteoporosis, worsening of cardiovascular disease, maybe causing dementia. Although, that is still debatable. So in this trial, he was looking at patients that had a biochemical recurrence, a PSA relapse, and was evaluating monotherapy with olaparib, a PARP inhibitor. Now interestingly, in this study, patients were not mandated to have DNA repair defects to enroll in the trial. So it was open to everybody. They were required to have a PSA doubling time that was less than six months. It turns out their PSA doubling time was, I forget the exact number, but something around the three month range. So very similar to all of these M0 CRPC studies that have come through recently, SPARTAN, et cetera. So these patients had pretty aggressive disease as defined by their PSA doubling time. So the primary endpoint was a PSA reduction of 50% or more. So this is a pilot study. So there were only 20 patients enrolled. And only three of the 20 patients met the primary endpoint, so about 15% of the patients. However, another four out of the 20 had some reduction in their PSA, anywhere from 1% to 49%. So in total, about 35% of men had a serological response of some degree. So if you actually look at the poster, though, it's pretty interesting and telling. So four out of four patients with a BRCA2 mutation responded. And of those three that I told you about that met the primary endpoint, all three of those were these BRCA2 patients. One of four patients that had ATM mutations responded. And only one of 12 patients that were biomarker negative responded. So it's really fascinating. It suggests, I mean, it clearly needs to be validated in a larger study, but it suggests that there might be a ADT sparing approach that you could do for a select group of men, which is what I hear all the time from patient advocates around prostate cancer. What do you have for me that doesn't involve testosterone suppression? So really fascinating. That sounds very promising for patients with prostate cancer. What about some other cancer types, such as bladder cancer? There was a lot of great research all the way through the GU space. So for bladder cancer, there was really two that stood out to me. They stood out to me in regards to immunotherapy. Dr. Padmanee Sharma's group at the MD Anderson Center, the abstract number is 4511, so she was evaluating neoadjuvant durvalumab and tremelimumab. So durvalumab's a PD-L1 inhibitor. And tremelimumab's an anti-CTLA-4 inhibitor. So she was evaluating this combination in a pilot phase II study in patients with muscle invasive bladder cancer but were ineligible for cisplatin. Now, that's important because right now there's no FDA-approved therapies that are proven to be effective for that group of patients either in the neoadjuvant space or in the adjuvant space. So the standard of care approach for these patients is to move forward with cystectomy or radiation therapy alone, with the majority of them getting cystectomies followed by surveillance. So their relapse rate is very high. So trying to find some other therapy that can be effective for them is a huge unmet need right now. Now, there was a couple of posters at ESMO in 2018 that suggested neoadjuvant immunotherapy can be useful for them. Pembrolizumab was tested and atezolizumab also was tested. So this was really an interesting validation to see in a separate cohort if the same approach of a PD-1/PD-L1 inhibition approach can be useful for these patients. Because this is a neoadjuvant treatment only, their duration of immune therapy was also very short. That's the other really fascinating thing to take into consideration here. So weeks 1 and 5 is when they had their immune therapy. And the planned time to surgery was somewhere between weeks 9 to 11. So far the trial isn't complete. Their planned enrollment is around 35 patients, I believe. And they're just around 30 that have enrolled. So there was a 43% complete response rate, pathologic complete response rate, at the time of cystectomy. I believe 21 patients have gone on to cystectomy in this trial, so 43%. It's really high, which is fabulous and great because the pathologic complete response rate, it's not a perfect predictor of long-term overall survival, but it's a reasonable surrogate. I mean, it's not an FDA-approved or recognized surrogate endpoint, but it correlates fairly well with overall survival for these patients. But the other reason that that number is fascinating is because if you go back and look at the pembrolizumab and the atezolizumab data, this is a fairly consistent number across all three of these trials. Anytime you talk about immune therapies, there are side effects. But it was right in line with what we see consistently with immunotherapy. So around 17% had grade 3 immune-mediated adverse events. Two patients had a delay in surgery because of complications. The delay in surgery, I should say, was reported as more than 30 days. So it can cause problems. But it's helping to create this foundation that, maybe in the future, when we get the results from my phase 3 study, it will provide some additional neoadjuvant or adjuvant therapy for these patients that are in great need. And the other one very similar to this, just briefly, was by Ronald Dewitt. And the abstract number was 4530. So this was looking at somewhat of a similar population, patients that have non-muscle invasive disease, but a refractory to BCG, which is the standard therapy today. So if you're refractory to BCG, there's some other intravesical chemotherapy you can try. The response rates aren't particularly high. Or the other option is the cystectomy. This was a much larger trial, just over 100 patients were enrolled. And they were given standard of care. Pembrolizumab was the immunotherapy in this setting. The three-month complete response rate was 40%. Of those patients that were complete responders, the median duration was very long. In fact, the median duration was around a year, I believe. And at least half of those patients that were responders had a response of over a year. Wow, that's remarkable. Yeah. So if you compare the standard of care that they'd be getting alternatively, it would be a cystectomy. So that's quite impressive. That's really exciting. How about kidney cancer? Did you see any interesting presentations? There was some great presentations on kidney cancer about clear cell disease and biomarkers coming off of the recent JAVELIN study, et cetera, that Toni Choueiri did. And other people can talk to you about that, I suppose. But in the posters, what I found particularly interesting was this focus on non-clear cell kidney cancer. So clear cell makes up the majority of kidney cancer, around 75%. But there's still this 25% that we don't have a lot of great data for. There's a couple of trials like ASPEN, et cetera, that have established TKIs as the standard of care for them. But the response duration is not great, so trying to find other therapies that have a longer duration of response is important. And so if we look at the current armamentarium of options, immunotherapy is what we look to as far as possibly providing patients a long, robust response. So there was a couple of trials looking at immune therapies with non-clear cell disease. So the first was by Michael Atkins, and the abstract number was 4569. So this was a report on KEYNOTE-427 cohort B. So KEYNOTE-427 is this two-arm trial with cohort A, or cohort one, whatever you want to call it, and is single-agent pembrolizumab in clear cell RCC. And cohort B is non-clear cell RCC. And this poster was just reporting on cohort B, the non-clear cell portion. So most of those patients-- and it was a fairly large cohort; 165 patients. Now, unfortunately, this somewhat suffers from all the research that's done for the most part in non-clear cell disease where they take all of these other histologies, they're somewhere around 8 or so, and they just lump them all together and say, you are non-clear cell disease. But we do know that they all have very distinct biology. So they fortunately did break them up at least into the top three pathologies. So 70-some percent were papillary, which is what we typically see. Of the non-clear cell histologies, that's the most common. Chromophobe was around 13%, and unclassified was around 15%. Oh, and the other important thing is they did do central pathology review, which is very important any time you're doing a non-clear cell study because the misdiagnosis rate is fairly high in this population. So these patients with any of these non-clear histologies got treated with pembrolizumab. And the overall response rate was quite high, around 24%. They specifically broke it up into those top three histologies. And the papillary objective response rate was 25%, chromophobe was around 10%, and the unclassified was over 35%. So it does show that there's a good rationale for immunotherapy in the non-clear cell histologies, at least, certainly, you could say for the unclassified and the papillary. Some people would argue that a 10% objective response rate in chromophobe isn't meaningful. There was some toxicity, as well, seen. Around 10% of patients had a grade 3-plus reaction. And this was a 165-patient trial. And six patients died directly from toxicity related to immunotherapies. So it really helps establish that immunotherapy can be useful in these non-clear cells. And that was recapitulated in a study by Dr. Rana McKay at Dana-Farber in their group there with Toni Choueiri, et cetera. And that abstract is 4583. And they looked at a similar idea with bevacizumab and atezolizumab. And this included, sort of, two cohorts, clear cell RCC with sarcomatoid features, or any non-clear cell RCC. They did not specifically break it up into the subtype of what the specific histology was for the non-clear cell group. But if you look at just that non-clear cell group of 39 patients, the objective response rate was 26%, very similar to the overall objective response rate in Dr. Atkins' study of 25%. So it's providing this promising new avenue of immunotherapy, demonstrating efficacy in this population. That's fascinating. And it's always good to look at the toxicities for sure. What else did you see this year? And did anything surprise you? As far as what surprised me or what other interesting things in the posters-- that's probably the best place, I mean, not only to meet people-- I love the posters for that-- but it's a great place to see new and developing biology of disease or understanding new technologies to monitor disease. I can't remember the abstract number off the top of my head, I apologize. But in the bladder cancer poster session, there was a poster looking at cell-free DNA. And not just presence or absence or quantity of it, but they were looking at the fraction of the cell-free DNA as a marker of patients having muscle invasive or non-muscle invasive bladder cancer. So that's just one example of many of the new, emerging uses of technology across these diseases. So it's really fascinating to see how people are thinking and using or repurposing a lot of technology for these cancers. It's a great place to go to generate ideas, I suppose, is what I'm trying to say. That's terrific. Again, today my guest has been Dr. Benjamin Maughan. Thank you for coming back to our podcast. Thank you so much. It's been a pleasure visiting with you, Lauren. And to our listeners, thanks for tuning into the ASCO Daily News podcast. If you're enjoying the content, we encourage you to rate us and review us on Apple Podcast.

Jun 10 2019

17mins

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Rank #7: Dr. Gilberto Lopes Highlights Key Presentations from ASCO Breakthrough

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At the inaugural ASCO Breakthrough Summit, attendees experienced the cutting edge of oncology and how rapidly-evolving science, technology, and research are transforming cancer care with remarkable new treatments and therapies. ASCO will return to Asia in 2021.

Oct 23 2019

9mins

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Rank #8: Dr. Fumiko Chino Tells Her Personal Story About Financial Toxicity

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ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Dr. Fumiko Chino, a radiation oncologist who specializes in the treatment of gynecologic breast cancers at Memorial Sloan Kettering Cancer Center. Dr. Chino had a circuitous way to oncology and is here to talk about how financial toxicity led to a new career for her and how it still affects her today. Dr. Chino, welcome to the podcast. Dr. Fumiko Chino: Thank you so much, Lauren. I appreciate the opportunity to talk to the ASCO Daily News about this very important topic. ASCO Daily News: We're glad you're here. Although your first career was as an art director, you come from a family with a medical background. Can you tell me about that? Dr. Fumiko Chino: Sure. So I would say you can't fight city hall. My mother is an oncologist. My brother's an oncologist, and my sister is also an oncologist. So it certainly was, I guess, to say, in the bloodline. But I had originally started a very fulfilling career in art and entertainment, and I was never really supposed to be a doctor. That wasn't in my grand plans. Dr. Fumiko Chino: Unfortunately, as we all know, cancer doesn't follow signposts. It does whatever it wants to do. And whenever I faced the treatment or diagnosis and ultimate death of my husband, I knew that I needed to do more. I needed to do more to improve the lives of others. I needed to make a bigger impact. What I normally say is that my husband was brilliant. He was going to change the world. And after he died, I had to be the one to change the world. ASCO Daily News: Mm, wow. I'm so sorry for your loss. So how did that lead to your decision to go to medical school for radiation oncology? Dr. Fumiko Chino: Yeah, so when I was in the hospital with my husband-- he was diagnosed in 2000. Well, he started having symptoms in 2005. He was diagnosed in early 2006. And that process was long and complicated. We were given a number of different diagnoses that weren't cancer, immediately. Because, again, if you have a healthy twenty-something man in your clinic, the first one through five of your differential diagnosis isn't cancer. Dr. Fumiko Chino: So like many young people, he went through a number of kind of false calls before ultimately getting his diagnosis of a high grade neuroendocrine carcinoma. And through the process of his cure, I realized that the people that you see in cancer care, each interaction is important. I originally actually thought I was going to go to nursing school. But coming from a family of oncologists, my sister said, you know what? You're not going to be happy as a nurse because eventually there's going to be some intern trying to tell you what to do, and you're going to know more than they will. And it's going to be frustrating for you. [LAUGHTER] Dr. Fumiko Chino: Which is accurate. I have the utmost respect for nurses. So she just said that I seriously consider medical school. And after my husband died, I thought about it for a long time. I went back to school, did some post-bac classes and ultimately decide to go to medical school. Dr. Fumiko Chino: I'm so grateful that I came to that path, but it was a hard path because I really struggled for a while after he died to kind of give my life purpose. But like what I said earlier, we were a team before. My plan was to continue working in arts, do arts nonprofit management. And he was going to be the one to make meaningful change in the world. But we're still a team. So anything I do now is still under our banner. ASCO Daily News: Absolutely. The sad fact of cancer care, we know, is that it's very expensive. And I know that your passion is around addressing issues around financial toxicity. I'm curious, what about the way insurance works surprised you when your husband was undergoing treatment? Dr. Fumiko Chino: Yeah, so all of the research that I've done is really rooted in and around personal experience. And so, I guess, in that way, I'm very selfish. Because when my husband was diagnosed, he had graduate student health insurance, and at the time we didn't really think of it. We said, well, he has health insurance. There will be costs, and we know that. We know cancer care isn't free, but it'll be manageable. Dr. Fumiko Chino: And what we didn't realize at that time-- and this is before the Affordable Care Act-- is that there wasn't the protections that were put in place. So for example, there were caps on how much the insurance company would pay. Those caps have been eliminated under the Affordable Care Act. But unfortunately, our part of what is being currently eroded in the-- I will say political environment that we are in now-- so the idea that you can now introduce a health insurance plan that does have a lifetime payment cap has been reintroduced. Dr. Fumiko Chino: So the coverage gap that we had is now potentially something that people could face today, when it had been eliminated in the last decade. I'm sorry, in the last five years. So what we found is that his insurance just stopped paying after a certain dollar amount. Which, with a cancer diagnosis, with any ongoing treatment, you understand that that's going to be continuing to be expensive. There's chemotherapy. There's scans. There's office visits. There's, unfortunately, hospitalizations for my husband, and there's need for supportive services. Dr. Fumiko Chino: And so those are all added to essentially the dollar amount. And after a certain point, his health insurance said, you're done. There's no more money that we will pay for his cancer care. And that was a huge shock to me, and is, unfortunately, is, again, what people are at threat for today, that at some point their insurance, if they have one of these, what I call sham insurance plans, that they have a serious diagnosis like cancer, that they will meet their max, meaning that the insurance company won't pay anymore. Dr. Fumiko Chino: The other thing that was surprising to me is that there was no cap on what we would pay. So the protections that were placed under the Affordable Care Act are that there is an out-of-pocket max, meaning that once you reach that level, that the insurance company will pay 100%. Those caps are high under the current marketplace plans for 2020. For a family plan they're $6,400. Sorry, $16,400. So that's incredibly high for a family to pay for a single person with a cancer diagnosis. Dr. Fumiko Chino: But at least it's a cap, whereas when my husband was diagnosed, it was literally a bottomless hole that we could throw money into. And it never seemed to make the difference in terms of what our balance was going to be. When he died, I owed hundreds of thousands-- I'm sorry, he owed hundreds of thousand dollars in medical bills. And I was really hounded by collectors for a decade afterwards. Dr. Fumiko Chino: It was actually only recently that I found out I wasn't responsible for that debt. And it really was the huge weight that lifted off of me. Because in my mind, I'd always been like, well, this is going to get me some time. And the whole life I was building now, the new career I have as a physician, I kept thinking, well, they're going to find me eventually. ASCO Daily News: Wow. What do you think clinicians need to know about financial toxicity in terms of how it affects patients and their families in the long term? Dr. Fumiko Chino: I think that physicians really need to think of this as being an insidious process. And the person who walks through their door with a new cancer diagnosis may not have problems with their finances, with their insurance, with their bills. And they may not realize that this is a problem that can work in the shadows. And you can be months or even maybe years into your cancer diagnosis before being faced with problems. Dr. Fumiko Chino: But what we know and what we have excellent evidence for is that it's financial toxicity can affect quality of life. It can affect the satisfaction you have with your cancer care, and ultimately can compromise the quality of the cancer care that you receive. So people will be cutting corners because of their costs. They'll be taking less of their medication. They'll be skipping scans. Dr. Fumiko Chino: We know that cancer survivors, of which there's a growing population in the United States, are missing out on, for example, mental health care or getting their glasses replaced. Young survivors are facing job lock, which is when they basically can't fulfill their maximum career potential because they're scared of changing jobs because of their health insurance. Dr. Fumiko Chino: Ultimately, we know that there's these huge family and personal burdens. We have medical bankruptcies. We have people who are literally losing their homes because of the financial burden of their cancer treatment. And the outcomes outside of just the personal and family effects can increase your risk of death. So this problem isn't something that will necessarily walk into your clinic and say, here I am. I have this problem. It can erode slowly over time. Dr. Fumiko Chino: It's just like any toxicity. Someone comes in with peripheral neuropathy, they say, it's a little numbness and tingling in my fingers, but it's OK. I can still do my activities of daily living. And then that can get worse and worse and eventually it can be disabling. And the same thing with financial toxicity is that it's a process. And my goal is to stem the tide of that process. Like any side effect in cancer cure, though, it's going to be hard to eliminate completely. ASCO Daily News: Absolutely. Thank you so much for continuing to spread the word about financial toxicity and sharing your personal story. It's been a pleasure speaking with you. Thanks so much for being on our podcast today. Dr. Fumiko Chino: Absolutely. Thank you so much for having me. And to our listeners, thank you for tuning in to the ASCO Daily News podcast. If you're enjoying the content, we encourage you to rate us and review us on Apple podcast. [MUSIC PLAYING] If you like what you hear from the ASCO podcast, please let us know. Take our listener survey and help shape the future of the ASCO Podcast Network. Visit podcast.asco.org and click on the survey link. Once again, that's podcast.asco.org. The survey will just take a few minutes to complete and will help us get to know you better. Thank you so much for listening. 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.

Nov 21 2019

10mins

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Rank #9: Dr. Nathan Pennell Highlights Key Poster Presentations in Lung Cancer from ASCO's Annual Meeting

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Dr. Nathan Pennell Highlights Key Poster Presentations in Lung Cancer from ASCO's Annual Meeting.

Jun 10 2019

7mins

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Rank #10: Dr. Karen Tedesco Discusses How the IMpassion130 Study Will Inform Metastatic Triple-Negative Breast Cancer Care

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Welcome to the ASCO Daily News Podcast. I'm Lauren Davis, and joining me today is Dr. Karen Tedesco of New York Oncology Hematology to discuss the impassioned 130 results in triple negative breast cancer. Today, we are discussing this aggressive form of breast cancer that is particularly difficult to treat because it's unresponsive to hormone and HER2-targeted therapies, leave patients with limited treatment options and a poor prognosis. Dr. Tedesco, welcome to the podcast. Thank you, Lauren. It's a pleasure to be here. An important treatment advance came in March 2019 when the FDA granted accelerated approval of atezolizumab, the first cancer immunotherapy regimen for breast cancer. Could you speak to the phase 3 and IMpassion 130 results, which led to the approval of this drug, in addition to the broader treatment landscape? Yes, so the IMpassion 130 trial was a multi-center, international, double-blind, placebo-controlled randomized trial that included 902 patients who had locally advanced or unresectable metastatic breast cancer that had the triple negative profile, the ER, PR, and HER2 all being negative. The patients could not have received chemotherapy for metastatic disease previously, but could have received chemotherapy in the adjuvant setting, including a taxane, as long as it was a year or more prior to enrollment in this study. And the study looked at the atezolizumab or a placebo given on days 1 and 15 every 28 days in conjunction with Nanoparticle Albumin-Bound, or NAB, paclitaxel at 100 milligrams per meter squared given on days 1, 8, and 15 of an every 28-day cycle. And they prospectively assessed for PD-L1 expression and called positive anything that expressed over 1% of the tumor area staining for the PD-L1 was considered a positive. And in patients whose tumors expressed the PD-L1, the median progression-free survival was 7.4 months for the treatment arm, including the atezolizumab and NAB paclitaxel, and 4.8 months for those that received the NAB paclitaxel plus placebo. The progression-free survival hazard ratio was 0.6 with a p value of less than 0.001 in favor of the treatment arm with the atezolizumab. The objective response rate was 53%, as compared to 33% for patients who received the atezolizumab and those who received the placebo. The overall survival data was not mature at this time, but when this trial was published in the New England Journal of Medicine in October of 2018, for the intention to treat population, median overall survival was 21.3 months with the atezolizumab and NAB paclitaxel compared to 17.6 months for the NAB paclitaxel and placebo. And for patients who had tumors that were PD-L1-positive, the median overall survival was 25 months for those who received the atezolizumab with the NAB paclitaxel as opposed to 15.5 months for those who received the NAB paclitaxel and placebo. So I'm curious. Do patients have immediate access to this treatment? Yes, they do. I've ordered this for a couple of my patients now since the time of this approval, and I've not had any difficulties in terms of getting approval for the medication. I will say, particularly for those of us in smaller communities, I think the biggest obstacle is getting the PD-L1 testing done and communicating with pathologists about the particular companion diagnostic test, the Ventana PD-L1 Assay that was approved in conjunction with approval of this regimen. So for me, I think that's been the biggest delay in access for the patients. But when I've ordered the medications, they were able to get them right away. That's great. We always wonder about side effects, so what should specialists tell their patients? So many of the most common side effects on this trial were actually those that we would probably think of as being more typical of the NAB paclitaxel, so alopecia, peripheral neuropathies, nausea, fatigue, neutropenia, decreased appetite. Certainly with any of the immune therapies, as many of us are getting more familiar, there are some toxicities we have to be aware of that are different than typical chemotherapy, and those largely include autoimmune-mediated toxicities So in this particular trial, there were some autoimmune-mediated hypothyroidism episodes, and those can be pretty easily managed. There was one autoimmune hepatitis that was quite severe. Other autoimmune toxicities I think we need to be mindful of include pneumonitis and colitis, both of which were rare on this trial. And rashes can be another thing. So even though this is the first immunotherapy approved for breast cancer treatment, many of us who treat other types of cancers out in the community are certainly gaining a lot of familiarity with these type of drugs. So I don't think anything was seen in terms of toxicities on this trial that was unanticipated. That's good to know. Were there any surprises in the trial results? I didn't think there were any surprises. I was happy to see that favorable results seemed to correlate with PD-L1 expression because again, I think that gives us a marker to look at for our patients and hopefully be able to best advise patients, depending on their molecular testing, whether a treatment is likely to be helpful to them or not so that we're not subjecting someone to needless toxicity if they're not likely to get significant benefit from the addition of a new drug. That's true. What do you think's on the horizon for breast cancer studies? Well, I think in the realm of immunotherapy, certainly there are going to be other immunotherapy drugs, likely in combination with chemotherapy, that are being looked at. There's going to be more studies coming out about immunotherapies in the neoadjuvant setting, particularly for the triple-negative profile breast cancer because that complete pathologic response can be a good surrogate in some instances for other outcomes and can more rapidly generate information. I think with triple-negative breast cancer in general, what we're learning more about is that we can't just lump all these patients with triple-negative profile together as if they're one homogeneous group just because they don't express estrogen, and progesterone, and HER2 receptors on their breast cancer. So some of these, I think we're trying to identify what makes them unique and what particular drugs might be good targets for them. So some of these triple-negative profile breast cancers may have androgen receptor expression and potentially respond well to anti-androgenic hormonal therapies, like we would use in prostate cancer, so things like bicalutamide, or enzalutamide, or understudy. PARP inhibitors are being looked at more in the triple-negative profile breast cancers, particularly those for women who have germline BRCA mutations, and even those who may have somatic BRCA mutations, or other types of mutations like PALB2 in their tumor. So as we're doing more gene expression profiles on tumor, that can help us identify some appropriate targets for these patients with this oftentimes difficult-to-treat profile of breast cancer. Absolutely. Again, today my guest has been Dr. Karen Tedesco. Thank you so much for being on our podcast today. Thank you, Lauren. And to our listeners, thank you for tuning into the ASCO Daily News Podcast. If you're enjoying the content, we encourage you to subscribe, rate, and review us on Apple Podcasts.

Aug 22 2019

8mins

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Rank #11: Dr. Megan Kruse Discusses a New Treatment for Metastatic Breast Cancer

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ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Lauren Davis, and joining me today is Dr. Megan Cruz, a medical oncologist at the Cleveland Clinic who treats patients with breast cancer. ASCO Daily News: Today we're talking about a new therapeutic option for patients with metastatic breast cancer who carry the PIC3CA mutation. Dr. Cruz, welcome to the podcast. Dr. Megan Cruz: Good morning. Thank you for having me. ASCO Daily News: We're glad you're here. ASCO Daily News: So the PIK3CA is a commonly mutated gene in HR positive and HER2 negative advanced breast cancer. What kind of tests are used to detect this mutation? Dr. Megan Cruz: Yes, so that's correct. The PI3 kinase mutation is found in about 40% of hormone receptor positive HER2 negative advanced breast cancer cases. And this mutation can actually be detected by a variety of tests, many of which are convenient for our patients. Dr. Megan Cruz: Most commonly, we use tissue-based testing. And that can be samples of tissue that have been archived from either a patient's initial breast cancer diagnosis or a newer biopsy from a metastatic site. If neither of those places can be accessed or that tissue sample is no longer available, patients can have testing run on a blood-based sample. And this is often very helpful for patients who potentially have bone-only metastatic disease. ASCO Daily News: Are new agents are available to treat this form of cancer? Dr. Megan Cruz: Yes. So earlier this year, we had FDA approval of a new medication called alpelisib, which is used in combination with endocrine-based therapy in the form of fulvestrant in order to treat patients with the PI3 kinase mutated breast cancer. ASCO Daily News: And how effective is this treatment in terms of survival or overall survival? Dr. Megan Cruz: So this treatment was studied in the SOLAR-1 trial. And in that trial, it was found that there was a progression-free survival advantage for patients who received the combination of alpelisib and fulvestrant compared to placebo and fulvestrant. And that difference at 20 months was approximately from 11 months with alpelisib and fulvestrant from 5.7 months for the placebo fulvestrant combination. ASCO Daily News: And what do clinicians need to know about side effects? Dr. Megan Cruz: So there are some unique side effects with this medication, alpelisib, that clinicians will need to pay attention to. The most common ones are hypoglycemia and rash, which are generally pretty easily managed, but we have to be aware of them. Dr. Megan Cruz: When starting a patient on this medication, they need to have fasting blood sugar testing as well as hemoglobin A1C testing done prior to starting as a baseline. And then shortly after initiation of the medication, we recheck these labs to make sure that they're staying stable. Dr. Megan Cruz: If the blood sugar is rising, it's recommended to do more frequent monitoring and consideration of starting a medication like metformin to help control the blood sugars. In terms of the rash, that can actually be dealt with in a preventative way, where patients can be started on prophylactic antihistamine medications along with the start of alpelisib. And then if the rash does happen once they're on the medication, we often use either topical steroids or oral steroids to help control it. Dr. Megan Cruz: The last toxicity that I think that the clinicians should be aware of his diarrhea, which is one that we're more familiar with managing from other chemotherapies and targeted agents. So typically, use of our common anti-diarrheal medications will help to control that. ASCO Daily News: What do you think's on the horizon for metastatic breast cancer treatment? Dr. Megan Cruz: I think that we will continue to see medications like this that are targeted for specific mutations that we find in a patient's breast cancer. And then along with that, I think we'll be combining these targeted medications potentially with immunotherapy moving forward. I think those are the new horizons for metastatic breast cancer treatment. ASCO Daily News: Again, today my guest has been Dr. Megan Cruz. It's been a pleasure speaking with you. Thank you for being on our podcast. Dr. Megan Cruz: Absolutely. Thanks for having me. ASCO Daily News: And to our listeners, thank you for tuning into the ASCO Daily News Podcast. If you're enjoying the content, we encourage you to rate us and review us on Apple Podcast. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

Dec 19 2019

4mins

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Rank #12: Dr. Andrew S. Epstein Highlights Key Sessions from the 2019 Supportive Care Symposium

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Nov 07 2019

17mins

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Rank #13: Sarcoma: Dr. William D. Tap, Part I

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In part one of this two-part podcast, William D. Tap, MD, of Memorial Sloan Kettering Cancer Center, discusses new advances in treating patients with sarcoma.

May 21 2018

19mins

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Rank #14: Challenges and Solutions to Establishing a Mutually Respectful Workplace

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Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Dr. Charles R. Thomas, Jr., Chair of the Department of Radiation Medicine at Oregon Health and Science University, who served as chair of the very important education session at the annual meeting this year. It's titled, Establishing a Mutually Respectful Workplace. Also joining me today is Dr. Colin Weekes, a GI medical oncologist at Massachusetts General Hospital, who co-wrote an educational book article related to topics around interactions in the workplace that leave lasting effects. Dr. Weekes also presented his personal stories about being discriminated against by patients based on his race during the session. The session also included stories about inappropriate comments made by a colleague about a person's ethnicity, gender, and sexual identity, and also some solutions to how to counter them. Sometimes people make these comments, and they think they're perceived as jokes by the person saying them. But they are not, and they have long-lasting, negative consequences, and they can impact morale. With that being said-- Dr. Thomas, Dr. Weekes, welcome to the podcast. Thank you for having me. Yeah, this is great. Thank you. Dr. Weekes, as education program chair, what were some of your hopes for the outcomes following the presentation? Do you think it led to meaningful discussion about how people treat each other at medical institutions? Yeah, so I think for me the real goal of this session was to just, I think, initiate conversation and to provide a platform in which individuals of different backgrounds and perspectives in the workplace can have an open and honest conversation about how to address some of these issues-- and I think simultaneously provide tools, as Dr. Thomas said, to go beyond just a conversation, but implementation of problematic processes to try to address this topic. Since the annual meeting, I have gotten feedback from members of my own institution about how much they enjoyed watching the session online and how impactful it was. And I've also received similar types of feedback from individuals from across the country. So I think at the end of the day, it served a nice purpose to once again initiate this conversation and to be thoughtful about how we as practitioners in our work lives can help one another to make everyone's experience better. So we're hearing a lot about microaggressions. But how do you define that? And how should someone handle these types of comments? Basically, microaggressions represent verbal, behavioral, and/or environmental indignities that really can communicate hostile, derogatory, and really negative slights that insult a target person, or really a group. These type of messages can result in either individual or group marginalization and, in some respects, isolation. And at the end of the day, cumulative microaggressions can impact the quality of care given to patients. And it really goes back to probably the first thing you asked at the beginning of this podcast-- why do this? Ultimately, we want optimal patient care to be delivered to our oncology patients. Suboptimal behavior, which includes microaggressions, can take away from delivering high quality care. So at the end of the day, it's about the patient. Absolutely. Civility and respect in the workplace has made some inroads, but it seems like there's a long way to go. Your educational book article, Dr. Weekes, talks about uncivility. Can you explain what that is? And also, what is cultural humility, and how does one work towards that? So uncivility is really the action of being discourteous or impolite, so treating others with malcontent. And this can be done in a lot of different ways. And it can be sort of a disrespectful gesture. It can be jokes, as we hear every now and then. And so there's lots of ways this can happen. And even sometimes, it also could be a form of incivility when you see someone being mistreated and you remain silent. So I think that's the framework to think about civility and respect within the workplace. It's really, how would you like to be treated, and being respectful of others, regardless of what their station in the practice or the setting in which you're working is. And I think the goal of that then, at the end of the day, is if we're treating others with respect for manners, I think, as Dr. Thomas said, the patient experience, the patient outcomes are all better, because people are interacting with each other from a positive standpoint. I'd like to add to Dr. Weekes' comment. This may involve we practitioners having some intentionality, meaning being somewhat conscious that behavior is suboptimal. Let me give you a specific example. We have two new women faculty here in the Department of Radiation Medicine at OHSU, who started this academic year. One of the things that I personally have been conscious of, without anyone telling me, is to make a conscious effort not to interrupt them when they're talking. At an early age, boys easily feel comfortable interrupting girls. Young men feel comfortable interrupting young women. And these kind of early behaviors can migrate into the adult workplace. Sometimes you need to be conscious that you don't always need to get a word in, but that some of the behaviors that are reinforced in our male-dominated society can be modified, such as what I just gave as an example. So there needs to be some intentionality in how we approach our relationships. That's a really important change. So let's talk about patients for a moment. One of the things noted during the presentation is that the University of Michigan has rewritten its patients' rights and responsibility document to specifically call out harassment by patients. Do you think more institutions will follow? My answer is yes. Michigan is a leader in that realm with Dr. Jagsi and others. At OHSU we're actually piloting an app that people can have on their iPhone that gives contact and other information if and when this occurs at the bedside, and so forth. And the big picture is, the goal is to allow certain virtues to enter the workplace while other behaviors exit the workplace. Let me give you an example. On one hand, we want more gender equity moving into the workplace, and we want unconscious bias to move out of the workplace. We want a psychological safety to move into the workplace and increase that, and, of course, exiting the workplace environment would be things like harassment. And so again, bringing in certain pluses such as microaffirmations into the workplace culture, and then microaggressions hopefully being minimized and leaving the culture. And so some of these tools, both in Michigan and other institutions, will hopefully allow health care providers to be able to adjust-- at times, on the fly-- when dealing with certain issues with patients and other care providers. Absolutely. Let's talk about the use of interventions to address issues when implicit bias and blatant discrimination occurs during visits with patients. How should physicians handle these situations? And at what point do you bring this to the attention of leadership? I think this is a challenging issue to address. So I think in many ways the person who is feeling discriminated against-- I think there's certain degrees on which this stuff occurs. And so if it's something that I feel like I can manage in a room with just education of the patient and helping them to understand what the individual roles of the people are in the room, that's something that I try to do in my own practice. One of the things that I do in my own practice when I meet a patient for the first time is I introduce myself, what my role is in the practice that I'm in. And then before I start to do the traditional medical interview, I ask the patient what are their goals for this particular visit. And so then I think, to some regards in that situation, the playing field is set. People know what each other's roles are, and I have a sense of what the patient wants to get from the visit. And many times, family members, if they're with them-- they will also discuss things that they want to know about. And then we start the visit. So I think, in many ways, that's a way to deal with that up front. I think if it becomes a repetitive thing, despite the fact of you re-educating the person that you're dealing with, then I think there's time in which you might go to the leadership and say these things are ongoing. How can you help me address these things? I think the other thing that leadership can do-- and I think this is what Dr. Thomas is also relating to-- is forming institutional policies about how do we address these issues. And I know in my own practice in my GI oncology group that I'm in, we actually had a conversation around how we as a practice are going to address these situations. And are we willing to have patients continue their care with our group if they are mistreating our colleagues, and to what degree we think that's appropriate. And so I think the other component of this-- and hopefully this session in and of itself gave the framework for us as colleagues to begin to, I think, have some uncomfortable conversations around these issues. And then also to understand the points of views of our colleagues. I think, to some degree, some of this stems from-- ignorance may be a harsh term-- but in terms of you don't understand each other and where other people are coming from in a given situation. And that's an important component of this conversation as well. And so I think the more that we as practitioners and colleagues discuss these issues, the easier it is to deal with these situations when they arise. In addition, senior leadership can use their agency, their authority, to explicitly-- not implicitly-- explicitly acknowledge what's happened or what's actually happening. Dr. William Tap from Sloan Kettering was actually on the ASTRO panel-- a Caucasian male. And the reason I bring that up-- some of the inherent authority that some folks have by virtue of our society allows one to really make a stand and make an impact in recalibrating the situation. Dr. Tap articulated this during the session. And really I want to echo that really senior leadership-- more often than not, males-- more often than not, majority males-- can make a big difference by calling out some of the inconsistencies and really helping the team recalibrate. What are some of the more specific tools? If this is a habitual problem, as Dr. Weekes talks about, one can develop a shared vision for multiple stakeholders-- initially, perhaps a small retreat, which can evolve into a written document that can actually breathe and evolve over time while being a professional facilitator to get major stakeholders in the same room. And really to value psychological safety-- I mentioned that earlier. That really refers to the willingness to take interpersonal risk, especially on the part of senior physicians, senior members of the department, who are aware of these-- admitting errors, asking questions, and/or seeking help are some of the aspects, some of the interpersonal risk involved in really imparting a cultural psychological safety. That's great. It sounds like there's a lot of relationship-building that happens that can help mitigate some of these situations. I imagine, though, when you're in a situation that becomes heated and you want leadership to play a role in the changing morale, what are some tips on how to communicate with leadership in a calm way, even in the heat of the moment? Depending on the situation, quite frankly, one can always respectfully walk away. And from time to time, I've had to do that. I'm in my early 60s, where I've had to physically say, you know what? I need to take a walk. I'll walk to the parking lot, or I'll walk outside and look at Mount Hood and recalibrate. So that's OK. People will respect you for that. That's OK. Really emphasize if there are going to be phases of cultural change, we need to somewhat begin with a code of contact-- conduct-- excuse me-- code of conduct. Eventually, curiosity is going to follow that. And that's going to lead to a shared sense of entitlement, or I really want to say a shared sense of-- excuse me-- ownership. And that's going to lead to really adaptation in a positive way in the workforce, learning and continuous improvement. Initially, there needs to be an initial conversation, and then there'll be iterative cultural changes. At the zenith of anger or something like that, one can always take a walk around the block and then recalibrate after the temperature settles down. That's good advice. So we talked a little bit about how colleagues treat each other, how patients treat physicians, and how to communicate with leadership in a respectful way to make long-lasting change. And it seems like these things can have long-lasting positive or negative effects, but all in all, affecting professional relationships. So how can institutions change the atmosphere to enable people of all genders, ethnicities, races, religions, and sexual identities feel included? I mean, I think the one thing that Dr. Thomas has sort of reiterated throughout this entire conversation is the role of leadership. And I think this is a situation where it starts with the leadership, and the leadership demonstrating in their own actions-- personal actions-- their support for all members of the team, and not be involved in some of these conversations, jokes, microaggressions that occur. And then when they witness it, however innocent or benign they may be, is to address it. And it doesn't necessarily require to have a large conversation. It's just, hey, maybe that's not the best way to speak or approach the situation. And a lot of times, little things along the way go a long way to promoting an environment. And then I think, as Dr. Thomas has also said, is that there has to be an institutional approach to this in which there is a framework that's defined by the institution in terms of what is the code of conduct within our individual institutions, and also outline what are the steps that would occur if different degrees of egregious actions occurred? And so I think that those two things-- that's really the critical foundation is the leadership exemplifying what they want the environment to be, and then the institution providing the framework in which we are supposed to conduct ourselves at work. And I think as we are having more open conversations about these issues, I also think then we will begin to-- when we see things that we don't think are appropriate, instead of maybe not saying anything or walking away, you may say to your colleague, hey, maybe you can think about this a different way. And I think a lot of times, these individual conversations go a long way in the appropriate framework. I agree. Most institutions already have mandatory onboarding online courses that one needs to take as far as how to show respect in the workplace. In addition, not just at the department level, but really at the institutional level, there can be implicit bias training. That is available. It would be nice if that could occur before there's a major issue that bubbles to the top. And remember, at the end of the day, the more we're conscious of dealing with some of the issues of developing a mutually respectful environment in the workplace, at the end of the day, patient care can be benefited. And that's ultimately what we want, is a superior environment for optimal patient care to evolve and take place. Absolutely. Well, it's been a pleasure speaking with both of you today. I just wanted to thank you for joining us on the podcast. Thank you very much. Yes, thank you. And to our listeners, please read the educational book article, Establishing a Mutually Respectful Environment in the Workplace-- a Toolbox for Performance Excellence. And visit the meeting and slide section on ASCO.org to watch the powerful presentation about challenges and solutions to improve doctor-patient relationships and relationships with colleagues. And also, thank you for tuning in to the ASCO Daily News podcast. If you're enjoying the content, we encourage you to rate us and review us on Apple podcast.

Oct 10 2019

19mins

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Rank #15: Immuno-Oncology: Dr. Catherine Lai

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Dr. Catherine Lai, of the National Heart, Lung, and Blood Institute at the National Institutes of Health, discusses new immunotherapies aimed at decreasing relapse rates in patients with leukemia.

Feb 23 2017

12mins

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Rank #16: Dr. Priya Rastogi Discusses How the KATHERINE Study Will Inform Early Breast Cancer Care

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Welcome to the ASCO Daily News podcast. I'm Lauren Davis. And joining me today is Dr. Priya Rastogi, who specializes in the diagnosis, treatment, and prevention of breast cancer at the Magee-Womens Hospital of the University of Pittsburgh Medical Center. And she's also the senior associate medical director for the NSABP Foundation. Today, we're discussing the topic of recurrence among patients with HER2 positive breast cancer, progress and providing more aggressive therapies in early breast cancer for those patients whose cancer is more likely to recur. Namely those with residual invasive disease following taxane and trastuzumab based treatment given before surgery is our area of focus. Dr. Rastogi, welcome to the podcast. Hi, Lauren, happy to discuss the exciting results from the KATHERINE study. We're glad you're here. So as an investigator of the KATHERINE study, I'd like to hear a little bit about some of the findings. So I understand that the study showed that T-DM1 reduced the risk of disease recurring by half compared with trastuzumab in HER2 positive early breast cancer. Yes. So in terms of background information, patients with HER2 positive early breast cancer receiving neoadjuvant treatment had favorable outcomes if they achieve a pathological complete response. But patients with residual breast cancer in the surgical specimen have a higher risk of recurrence. And so that's some of the rationale of how the KATHERINE study was set up. The KATHERINE trial was an open label study with 1,486 patients with HER2 positive early stage breast cancer who received neoadjuvant chemotherapy plus HER2 targeted therapy that included a taxane and trastuzumab followed by surgery. And then all these patients had residual invasive disease in the breast and/or actually in lymph nodes. So within 12 weeks of surgery, patients were assigned to either T-DM1 or to trastuzumab. And as you mentioned, the primary endpoint was IDFS. And so in the KATHERINE study, T-DM1 significantly reduced the risk of developing an invasive disease free survival event by three years by 50%. And this corresponds to an absolute improvement in three year invasive disease free survival of 11 percentage points. So this is really exciting. So the invasive disease free survival rate was 77% with trastuzumab, and it increased to 88.3% with T-DM1. So the KATHERINE trial demonstrates that neoadjuvant therapy can be used to identify patients at increased risk for recurrence based on less than optimal response to standard neoadjuvant therapies who can then benefit by switching to T-DM1. The overall survival analysis has not yet matured. We had a total of 98 deaths, 56 deaths with trastuzumab and 42 with T-DM1 for a hazard rate of 0.7. So clearly, this study will need more follow up. So the FDA approved T-DM1 as adjuvant treatment for this patient population. Do patients have immediate access? Yes, so this is also exciting news that the US FDA approved T-DM1 for the adjuvant treatment in patients with HER2 positive early stage breast cancer with residual invasive disease after neoadjuvant taxane trastuzumab based therapy. The results and approval form the foundation of a new standard of care in patients in this setting. And this should lead to access and availability for patients. Patients should discuss with their physicians and their insurance providers. That's exciting. So one of the things we always think about are side effects. What should specialists tell their patients? Yeah, so as you mentioned, side effects are very important. So the safety profile of T-DM1 is as expected from what has been seen in the metastatic setting in the use of T-DM1. The main adverse events in our study was a decrease in platelet counts, an increase in sensory neuropathy and liver enzymes compared to trastuzumab. Although, these side effects are mostly mild. Fatigue and nausea were also greater. But they were manageable and reversible. So the side effect profile is similar to what had been seen in the metastatic setting and the efficacy is fantastic for this drug. Oh, that's great. Were there any surprises in the results? So the analysis by the subgroups demonstrated that there was a benefit across all the key subgroups. So for example, patients with operable or inoperable cancers at presentation, hormone receptor positive or hormone receptor negative, post neoadjuvant positive or negative nodes, and even patients with very small residual disease all had a tremendous benefit from T-DM1. So this is also very exciting that all the subgroups benefited. So what do you think is on the horizon for breast cancer studies? That is also a very important question. So immunotherapy is a type of cancer treatment which also helps the immune system fight cancer. And immunotherapy has been approved in other cancers. One type of these drugs is atezolizumab, which belongs to a class of drugs known as the checkpoint inhibitors. By inhibiting the checkpoint proteins such as PD-L1 and PD-1, these drugs enhance the ability for the immune cells to attack cancer cells. So recently, the FDA approved atezolizumab in combination with chemotherapy for the initial treatment of women for advanced triple negative breast cancer with PD-L1 positive tumors. So the NSABP Foundation in collaboration with the German Breast Group is conducting a phase III study, it's NSABP B59 [INAUDIBLE], for patients with early stage high risk triple negative breast cancer. And so this trial is evaluating neoadjuvant chemotherapy with atezolizumab or a placebo followed by surgery. Patients then receive an additional six months of either atezo or placebo after surgery. And the co-primary end points are pathological complete response and event free survival. And this study will address if neoadjuvant atezolizumab in combination with neoadjuvant chemotherapy followed by adjuvant atezolizumab will improve outcomes in this high risk patient population. That's fantastic. It sounds like there's a lot of things to look forward to. Again, today, my guest has been Dr. Rastogi. Thank you so much for being on our podcast today. It has been a privilege. And thank you for inviting me to talk about the KATHERINE study. And to our listeners, thank you for tuning in to the ASCO Daily News podcast. If you're enjoying the content, we encourage you to rate us and review us on Apple Podcast.

Jul 18 2019

7mins

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Rank #17: Hematologic Cancers: ASCO 2017

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ASCO Daily News Editor-in-Chief John Sweetenham, MD, FRCP, FACP, discusses notable hematology abstracts from the 2017 ASCO Annual Meeting.

May 24 2017

18mins

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Rank #18: Dr. Larissa Korde Discusses the Implications of the New USPSTF Recommendations on Risk Assessment, Genetic Testing for BRCA Genes

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Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Dr. Larissa Korde whose research interests focus on breast cancer treatment and prevention at the National Institutes of Health. Today we're talking about breast cancer screening as it relates to bracket gene mutations. Dr. Korde, welcome to the podcast. Thank you for having me. We're glad you're here. Although 12% of women in the United States will develop breast cancer sometime during their lives, approximately 72% of women who inherit the BRCA1 mutation and about 69% of women who inherit the BRCA2 mutation will develop breast cancer by the age of 80. Recently the US Preventive Services Task Force expanded the recommendation of patients who should be screened for the BRCA1 and BRCA2 genetic mutation, which is associated with multiple cancer types. How did this update come about? The US Preventive Services Task Force last presented guidelines on this topic in 2013. The recent publication in the Journal of the American Medical Association is an update, and it reviews the evidence that has come about since 2013. It's important to note that these recommendations are not actually about who should be tested for BRCA1 or 2 mutations. What the recommendations address is really who should be screened and that screening would be evaluation of family history. So the screening with family history is designed to identify which patients should be referred for further evaluation by a provider experience in genetic counseling and testing who can then make recommendations regarding actually having a gene test. The task force recommends that primary care providers assess women with a personal or family history of breast or ovarian cancer and ovarian includes fallopian tube and peritoneal cancers. And they also recommend that those who have an ancestry associated with a BRCA1 or 2 mutation should be assessed using a family history assessment tool. There are a number of brief assessment tools that can be used in the clinic setting and are designed to assist providers in identifying which patients should be referred for genetic counseling and then if appropriate for genetic testing. Also the task force recommends against routine assessment and referral in patients that do not meet their set criteria. The important update is that compared to the 2013 guideline, the population for whom risk assessment is deemed appropriate is broader, and specifically it's been expanded to include those women with a personal history of breast or ovarian cancer and those with a specific ancestry. The ancestry part of this was met to increase awareness of the strong association between BRCA1 and 2 mutations in Ashkenazi Jewish ancestry. Again, though, this is not a blanket recommendation that all women of Ashkenazi Jewish ancestry should be tested for BRCA1 and 2 mutations, just that the knowledge of ancestry should consider-- that should trigger additional evaluation. There are certainly schools of thought that a more inclusive approach is needed. For example, there are folks who advocate for universal mutation testing in all women with breast cancer or all women with Ashkenazi Jewish descent while others favor a more targeted approach. These recommendations call for the more targeted and step-wise approach. So the first step would be evaluation of personal and family history and ancestry followed by referral of patients that meet a certain threshold of risk. And then finally followed by testing if it's appropriate after counsel. That's great. Sounds like it's a lot more about finding out who really needs to be tested and not so much about the test itself. So how can this update improve outcomes for patients? Well, I think the basic goal here is that if we can do a better job at identifying who to screen for the BRCA1 and 2 mutation, then we can do a better job of offering appropriate interventions to those who take the test and test positive. And that can take many forms. The most obvious here is that those who have the highest likelihood of having the BRCA mutation will be referred for the appropriate counseling, and then they can make the decision with the advice of their providers about whether or not to undergo testing. And, of course, there are also downstream effects. Once a patient is identified as having a BRCA mutation, she can be offered preventive interventions such as prophylactic mastectomy or [INAUDIBLE], and she can be offered more intensive cancer screening. It's important to note here that the recommendations were expanded to include women with a personal history of cancer because we know that these women are at risk for developing a second cancer. And that's important information, particularly for a patient whose original cancer was treated with curative intent. Something that was outside of the scope of this guideline but which I think is becoming increasingly important in the oncology community is that [INAUDIBLE] genetic information can now be used to select therapies for patients with cancer. Specifically PARP inhibitors are FDA approved for treatment of metastatic breast cancer in women with a germline BRCA mutation and are being studied in other cancers and also in the earlier stage study. So this information clearly has treatment implications. Lastly, the identification of patients that carry a BRCA mutation leads to what we call cascade testing. That is once you know someone has the mutation, you can offer mutation testing to their family members, and those who test positive can be offered appropriate intervention. I think that this is definitely a benefit. That sounds very promising. Do you have any concerns about the new guidelines in terms of how they will be interpreted? No real concerns about how the guidelines will be interpreted. I think they're pretty straightforward, and they do help to expand the population who should be eligible for testing or at least screen for referral to a genetic counselor. So I think it's important here to note that there's a lot of issues in genetic screening and testing that the guidelines do not address, primarily because there are not enough data on which to base recommendations. These are issues that I think will become more pressing in the future and hopefully can be addressed in future guidelines. One important issue with multi-gene panel testing. Since the guideline doesn't explicitly state what gene testing should occur, just that patients should be screened and referred, it does not get into which test should be used once someone is identified having it-- identified as having a high enough risk of carrying a mutation to be referred. Multi-gene panels are becoming increasingly prevalent, and there's a lot of variation in which genes are included in panels and even in whether a particular abnormality found is classified as a deleterious mutation, as a variant of uncertain significance, or as a benign polymorphism. Also some panels contain genes for which they're not clear clinical implications in terms of what cancer screening or preventive interventions should be offered to patients who carry these genes. So while this is outside of the scope of the guidelines, I think it's important because the information in the guideline is geared towards primary care providers. And so when they make a referral for genetic screening and testing, they need to be aware of the downstream consequences and particularly about how to counsel and treat a patient who is found to have the mutation other than BRCA1 or 2. This is something that's going to come up in clinical practice, and so I think it's important for providers to be educated about the range of possibilities. The other issue that I want to raise, which again is not addressed in the guidelines due to a lack of available data but which is nonetheless important for providers to be aware of, is direct to consumer testing. For example, one of the very kind of consumer panels that you see on TV all the time includes evaluation for one of the [INAUDIBLE] mutations in BRCA1 and 2 that are prevalent in the Ashkenazi Jewish population. So you could imagine a scenario where a patient with a strong family history comes in and she's asked about her family history of breast or ovarian cancer and then just says, oh, I already have the gene test. It was negative. And what that patient may mean is that they did this direct to consumer panel, and they don't have one of the three [INAUDIBLE] mutations. But it's not comprehensive testing. So if the family history is indicative, this person should still be referred to a genetics provider for counseling and testing that would include looking for all the possible mutations in BRCA1 and 2, not just these three [INAUDIBLE] mutations and possibly looking at other genes associated with breast and ovarian cancer as well. So without a working knowledge about what tests are out there, this is a patient who could be missed or who could be counseled inappropriately. That's a very important distinction. What should clinicians tell their patients who have questions or perceptions about over testing? I don't think these guidelines will lead to over testing. They identify appropriate specific populations of women that should be referred for a more thorough genetic evaluation. And the end result there is a referral for more information, not necessarily a test. After meeting with the genetic counselor, the patient can make an informed decision about whether or not to pursue testing and then about what type of testing to do. Actually I think under testing is much more of a problem-- is much more the problem that we currently face. Susan [INAUDIBLE] pointed out in her editorial that accompanied the Preventive Services Task Force recommendation that although it's estimated that about 15% of women with ovarian cancer have a BRCA mutation, studies have shown that less than 30% of such patients were tested. So the inclusion of women with a personal history of cancer in these guidelines is definitely an important step forward. Under testing is also a substantial issue in underrepresented minorities and those with a lower socioeconomic status. Access to care is an issue for those living in rural areas, and this is a problem that might be alleviated through things like telegenetics. I was listening to a talk yesterday about health disparities and how telemedicine might be helpful, and the speaker said that any provider interaction that does not require a physical exam can be done through telemedicine. I think that's true of genetic counseling. There are also ongoing studies evaluating alternative models providing genetic education and counseling, and I think these will become increasingly important in the future and can hopefully help to address the issue of under testing. Absolutely. What an important point. Again today my guest has been Dr. Larisa Korde. Thank you so much for being on our podcast today. It's my pleasure and thank you for having me. And to our listeners, thank you for tuning in to the ASCO Daily News podcast. If you're enjoying the content, we encourage you to subscribe, rate us, and review us on Apple podcasts. Also to listen to ASCO's other offerings, please visit ASCO.org/podcast.

Sep 12 2019

10mins

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Rank #19: Dr. Neelima Denduluri Highlights Key Poster Presentations in Breast Cancer from ASCO's Annual Meeting

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[MUSIC PLAYING] Welcome to the ASCO Daily News podcast. I'm Lauren Davis. And joining me today is Dr. Neelima Denduluri, a medical oncologist and Associate Chair of Breast Cancer for the US Oncology Network. Dr. Denduluri, welcome to the podcast. Thank you for having me. We're glad you're here. Today, we're talking about stand out poster presentations from the ASCO annual meeting that really stood out to you. Can you tell me a little bit what was interesting about this year's meeting? I really enjoyed this year's ASCO because I thought there was a lot of focus on survivorship, prevention, and really focusing on our patients across the cancer care continuum. With regards to supportive care and what we do during treatment to make sure that our patients get through their treatments include reducing their risk of their blood counts dropping from chemotherapy. A way that we often employ preoperative chemotherapy or adjuvant chemotherapy is in the dose-dense fashion, meaning that we give the chemotherapy at more rapid intervals. And one thing we've always wondered is, do we really need to use growth factor in a very commonly used regimen, the dose-dense AC paclitaxel regimen? And interestingly, abstract 517 confirmed something that a lot of us have been doing in practice. And that is that for patients that don't have high risk of neutropenic fever, they don't need pegfilgrastim to reduce their risk of complications from paclitaxel being given in a dose-dense fashion. I think that from a quality of life perspective for patients, that is dramatic. As we know, filgrastim and pegfilgrastim do cause arthralgias, low-grade fevers. And I thought that this was a step in the positive direction that we finally have data that suggests that we really don't need to use it in the paclitaxel portion in most of our patients. Additionally, it reduces the financial toxicity that our early breast cancer survivors have to go through as well. Similarly, one thing that our patients struggle with is diarrhea with a drug that we use for HER2 positive breast cancer in the early breast cancer setting called neratinib. And one limiting issue with neratinib has always been the diarrhea. The control study, which was abstract number 548, showed that those patients that we adequately recognized and educated them in saying, listen, diarrhea is an issue with neratinib, and we gave them prophylactic loperamide-- this trial also added budesonide and colestipol to loperamide prophylaxis for one to two cycles-- and found that it reduces the severity and duration of the diarrhea in those patients being treated with neratinib for their HER2 positive breast cancer. So I thought both of these were really interesting in terms of moving the field forward in terms of tolerability. And one is to de-escalate care. And one is to escalate care. So I want to shift gears a little bit to a subtype of breast cancer that we often focus on, triple negative breast cancer, to improve outcomes. We know that chemotherapy is paramount in this disease to reduce the risk of recurrence and improve disease free and overall survival in the early breast cancer setting. One thing that we don't know is who we need to add carboplatin to in addition to standard anthracycline and taxane-containing therapy to improve outcomes. There have been multiple studies that have looked at this. And there are some confirmatory trials looking at this in the early breast cancer setting as well. One trial I want to highlight is the CALGB Alliance trial, which was presented in abstract 591. And what it showed was that regardless of treatment arm, pathologic complete response was associated with markedly better long-term outcomes. We also know that patients with any residual disease had significantly worse outcomes. Now, when looking at the whole population, the addition of carboplatin to standard neoadjuvant chemotherapy did not improve long-term outcomes. Additionally, it led to omission of standard chemotherapy doses such as paclitaxel in the patients that were treated with carboplatin. We know that dose density and dose intensity are very important to long-term survivals in triple negative breast cancer. So therefore, I thought that this was an interesting point that the authors made sure to make that the anthracycline and the taxane-containing part is very important. And if we add carboplatin, which is a very personalized decision, we need to make sure that the dose and that intensity and dose density are maintained because patients, they have worse outcomes. If the carboplatin is added, they have cytopenias, and we have to stop both the paclitaxel and the carboplatin. Sounds like a lot of promising presentations this year. Any surprising results? I don't think there were any surprising results. However, it was very gratifying, again, that certain subtypes of breast cancer are being looked at more closely. For example, abstract 546 looked at adjuvant enzalutamide for the treatment of early stage androgen receptor positive triple negative breast cancer. Growing research shows that triple negative breast cancer is a very heterogeneous disease. And this trial nicely took patients that received their standard adjuvant therapy. And then these patients went on to receive enzalutamide, which targets the androgen receptor, for one year. And the authors showed that it was very tolerable. And the enzalutamide side may be the next step in how we improve outcomes for this special subtype of triple negative breast cancer. Another abstract that was very interesting was abstract 552 that looked at the rates of osteonecrosis of the jaw in woman with breast cancer receiving bisphosphonates to prevent breast cancer metastases. We've always historically used bisphosphonates in the advanced breast cancer setting. However, we're increasingly using it in the early breast cancer setting. And it was gratifying to see that the prevalence of the osteonecrosis of the jaw was very low and patients that, for example, had dentures, or plaques, or chemotherapy, or corticosteroid use were not at higher risk for osteonecrosis of the jaw. I thought this was reassuring for our highest risk early breast cancer patients. Something else that we know from the breast cancer literature is that many of our patients have trouble adhering to adjuvant endocrine therapy. And that's very important in terms of improving outcomes. And there was a study, abstract 523, that showed that possibly patients that were in urban settings had lower adherence to adjuvant endocrine therapy. Additionally, patients that were ages between 41 and 74 were more likely to adhere to their adjuvant endocrine therapy. That was reassuring. However, we as a community need to do better at improving tolerability. We know that acupuncture, duloxetine, yoga, regular exercise, possibly vitamin D may also improve tolerability to these medications. One small feasibility abstract that I found interesting was 525, which enrolled 60 patients to receive tart cherry extract and showed that the patients that received the tart cherry extract actually had improved symptoms in terms of musculoskeletal symptoms from receiving this. Wow. So I thought that's hopeful. And that's kind of surprising in terms of moving the field forward in terms of tolerability, coming up with novel ideas to try and improve adherence to these medications. Absolutely. That leads in a little bit to my next question, which is, how do you talk to your patients about what you've seen and heard at the annual meeting? One thing that our patients always want to know after the annual meeting when I come back is, what did you learn, and how does it affect me? And I tell them that there are three major themes. One is all of these stress to us that we as providers need to do a better job in terms of improving tolerability to these medications, that we are looking at this, and there's a lot of great research to help with us. Second thing that we talk about is that the science is always dynamic. So what I may have said to you three years ago may change how I treat you now. And then for our new breast cancer patients, one thing that has come up, I think, and has been reiterated is that we really need to make sure and incorporate our care in a multidisciplinary fashion not only with the surgeons, the radiation oncologists, which is a team we've always traditionally made sure to include, but also our primary care physicians, our gynecologists to improve tolerability. That's great. What do you think is on the horizon for breast cancer care? I think that this is a phrase that we often use but I think that further personalization of therapy. For example, in the last eight months, I think that the way that we treat, for example, early HER 2 positive breast cancer has transformed significantly in that majority of patients that are treated for early breast cancer, now, we meet them upfront before their surgery to discuss whether we should give chemotherapy up front with HER 2 targeted therapy, or should we give it to them after surgery? And that's because we know that, those patients that don't achieve a pathologic complete response to HER 2 targeted therapy and chemotherapy, that we need to escalate their care, switch their care to other agents. So I think that there's going to be more of that in various subtypes of breast cancer in terms of more personalization. That sounds great. It sounds like there's a lot of promise for the future of breast cancer care. Well, it's been a pleasure speaking with you. I wanted to thank you for being on our podcast today. Thank you for having me. And to our listeners, thank you for tuning into the ASCO Daily News podcast. If you're enjoying the content, we encourage you to rate us and review us on Apple Podcasts.

Jul 24 2019

12mins

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Rank #20: Genitourinary Cancers: Dr. Adam P. Dicker

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Adam P. Dicker, MD, PhD, of the Thomas Jefferson University Sidney Kimmel Cancer Center, walks us through the debate about the value of local treatment for newly diagnosed metastatic prostate cancer.

Feb 01 2018

11mins

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