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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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Average Ratings
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Cover image of Cancer.Net Podcasts

Cancer.Net Podcasts

Updated 12 days ago

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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.

Rank #1: 2015 ASCO Educational Book - Using Social Media to Learn and Communicate about Cancer, with Michael A. Thompson, MD, PhD and Nathan A. Pennell, MD, PhD

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In this podcast, Dr. Michael Thompson discusses his article, “Using Social Media to Learn and Communicate: It Is Not About the Tweet” with Dr. Nathan Pennell.

Cancer Research News
Nov 10 2015
10 mins
Play

Rank #2: Leg Swelling After Cancer Treatment, with Andrea Cheville, MD, and Jennifer Bradt, PT, DPT, CLT-LANA

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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, we’ll discuss lymphedema, or swelling, in the legs after cancer treatment, including what can cause lymphedema, and how to prevent and manage it. This podcast will be led by Dr. Andrea Cheville, the Director of Cancer Rehabilitation and Lymphedema Services in the Department of Physical Medicine and Rehabilitation at Mayo Clinic in Rochester, Minnesota, and Jenny Bradt, a LANA-Certified Lymphedema Therapist and Clinical Lead Physical Therapist in the Department of Physical Medicine and Rehabilitation at Mayo Clinic.

ASCO would like to thank Dr. Cheville and Ms. Bradt for discussing this topic.

Dr. Cheville: Hi, I am Dr. Andrea Cheville, the director of Cancer Rehabilitation and Lymphedema Services at the Mayo Clinic in Rochester, Minnesota. And I am joined today by our lead lymphedema therapist, Jenny Bradt. Jenny, do you want to tell our listeners a little bit about your background?

Jenny Bradt: My name is Jenny Bradt, and I am the Clinical Lead Physical Therapist at the Lymphedema Clinic here at Mayo Clinic. I am a LANA certified therapist. We'll be talking about that a little bit later, and what I do in and out, every day, are treat patients with lymphedema.

Dr. Cheville: And I think it's worth noting that Jenny and I have been in this business for quite a while. I've been directing Lymphedema Services, largely for cancer patients, since 1999. I initially started my work at the University of Pennsylvania in Philadelphia. And, Jenny, has it been 30 years yet for you?

Jenny Bradt: Since 1995. That's a long time.

Dr. Cheville: No, not so long. Okay. Well, to start out with, we thought it might be useful to talk about what is lymphedema? And how does lymphedema differ from other kinds of swelling? And why does it happen frequently among patients with cancer? And it really comes down to a matter of plumbing. The cells of your body need oxygen and nutrients in order to survive. In fact, they don't last very long without both of those. And so the body transports very large volumes of oxygenated blood throughout the body. But once the blood has reached the tissue, it has to get back to the heart, which is not a mean feat. And in addition, all of the debris, the garbage that cells make—just like we make garbage, our cells make garbage—that also has to get out of the tissue.

And so, we have 2 sets of pipes to accomplish this task. We have our veins and the lymphatic vessels. And the veins principally carry fluid. Roughly 90 to 95 percent of the fluid that your heart pumps into any tissue is returned by the veins. And veins also will remove smaller molecules, and these proteins, fatty acids. But the big ones, and again, these are tiny by our perspective. Those are returned to the general circulation by the lymphatic system. So these are bits and pieces of dead cells, cells that die in our tissue, what we call long-chain fatty acids, large proteins, and bacteria.

And all of that solid waste material can build up outside of our cells, and it's the tiny, little lymphatic, what we call capillaries, that absorb those, and then through larger and larger lymphatic vessels, they eventually transport those. And actually, the lymphatic system pumps. It has muscle in the walls of the vessel, and it's remarkably efficient at moving this proteinaceous and other debris out of our tissue and to the lymph nodes. And the lymph nodes do 3 things. They regulate the viscosity of lymph, how thick it is. They remove debris that the body doesn't feel a need to recycle. And they identify harmful pathogens, and those are principally bacteria, because our skin is not a perfect barrier and bacteria get in through our skin all the time. And at the level of the lymph node that the immune system learns, "Hey, there's a problem." And that's assuming that there aren't just a few bacteria, but when we really have an infection. And it's a lymph node that the body mounts a response, which is why you may have palpated enlarged, tender lymph nodes in your neck, or in your armpit because those lymph nodes are busy fighting off an infection.

So for cancer, both for staging, to accurately stage our cancers, and to achieve local control, we remove or irradiate lymph nodes. There's also increasing evidence to suggest that some chemotherapeutic regimens can compromise our lymphatic system. But it's principally radiation and surgery have been implicated in causing lymphedema. Which brings us to, well, what kinds of cancer treatments are associated with lymphedema? And in truth, any cancer treatment that involves the removal or irradiation of lymph nodes can cause lymphedema.

And one aspects of lymphedema that continues to puzzle us is why it's delayed. And so large data sets have accumulated over time that guide us in understanding when lymphedema starts. And what we've learned, for the most part, it starts by the third year out, the third year following treatment. With most patients presenting in the first 2 years. But not immediately, and we think this is because that solid debris, that the lymphatics are responsible for removing, that builds up slowly in the tissue. It's not an immediate phenomenon. Although, for some patients who have severe damage or compromise of the lymphatics in the course of their cancer treatment, they may have swelling immediately. But often, it's a more gradual onset, and the protein builds up, the other debris, it's irritating to the body. The body is doing its best to handle the problem, which it knows isn't normal. And eventually, it causes low-grade inflammation, which many times, is the first indicator that a patient is developing lymphedema. They may have heaviness in their arm, their leg, or the affected body part.

Jenny, what are some other symptoms that patients often describe when they're—what we call Stage 0 or subclinical lymphedema—before we can appreciate swelling?

Jenny Bradt: Sometimes, those changes are sort of subtle. Obviously, they might notice that their ankles are bigger are at the end of the day, but by morning, they're back to normal. But some patients, especially lower extremities, say, "Well, my jeans fit tighter on one leg, or in one buttock, more than the other side." Or they just don't feel the muscles underneath their skin as much, where the skin just doesn't wrinkle as easily as it does with a less affected leg. The skin might feel thicker. It doesn't necessarily have to make a thumbprint, it's just this overall thickness. They might have veins on the top of their foot that are kind of disappearing. They don't notice them as much as the other side, and those would be early signs of lymphedema.

Dr. Cheville: So first, we have—not in everybody, but often—just the symptoms. Heaviness, maybe some aching, and a really important point is that this is a general diffuse feeling. Lymphedema, for the most part, does not cause focal pain. So cancer survivors who have pain in a knee or a wrist or a specific part of their affected limbs, that should not be blamed on lymphedema, and it should not delay a workup for an alternate explanation. But that heaviness, aching, particularly after activity, or if it's the leg standing for a long time, those can be the first signs followed by the subtle changes in volume that Jenny had described. But over time, the debris, the solid material builds up in the tissue, causes inflammation, and will cause scarring or what we call fibrosis. And it's simply collagen, loose disorganized connective tissue that over time, can accumulate and lead to an enlarged—sometimes, very enlarged—extremity. The arms and legs are most frequently affected. But because every tissue on our body, that's face, trunk, breast, genitals, create lymph, lymphedema can, essentially, affect any of our somatic tissues.

 So, Jenny, could you share some strategies that patients can use to reduce their risk of lymphedema?

Jenny Bradt: Yeah. I think it's important to emphasize that the most important thing to do is to observe your leg and if you note any swelling to treat it right away. Because it is easier to treat in early stages. And never feel that you have too little swelling to report. There's never going to be a time where there's too little swelling to report.

An important symptom to watch for is infection of the skin. The risk of developing a skin infection in the leg or legs that are at risk for lymphedema is greater because there's a delayed lymphatic flow in that leg. A skin infection, also called cellulitis, is relatively easy to diagnose and treat. However, if an infection is not treated quickly it can lead to much more swelling in the limb and make it more difficult for the lymphatic system to work well after the infection has resolved.

So any changes in color or temperature of the leg should be reported the same day you see them if they are there. So observe your leg. Become familiar with its normal color and appearance so that you can recognize changes if they occur. So for example, if your leg's usually a little pink when your feet are on the floor but not as much when they're elevated, and then you see that your feet stay red or pink when they're elevated, and they're red and warm, well, that's something that should be checked. Because it wasn't what's normal for your leg.

There's usually an identifiable cause to most cases of cellulitis, like an open area that allows microorganisms to invade the normal barrier of the skin. And for this reason, it's important to avoid situations that can cause cuts or scrapes in the skin. So if you do have a cut or a scrape on the affected leg, watch and make sure it is healing without any increase in redness to the area. And if you have an open area in the skin, avoid situations where bacteria can invade the wound, such as swimming in a lake.

Cellulitis in the leg can be related to fungal infections between the toes, and that's why it's absolutely important to treat and avoid athlete's foot. Athlete's foot causes cracks and web spaces between the toes. This allows microorganisms to invade the foot, so take care of your feet. Avoid walking with bare feet in public shower areas and locker rooms, and if you do have an athlete's foot infection, treat it with over-the-counter anti-fungal medications. There's powders and there's ointments, and if cracking of the skin is a problem, maybe an ointment might work better. But if you're always having sweaty, damp feet, well, a powder anti-fungal medication might work better. But the goal is to make your feet unwelcome for fungus. And it's important to keep your toes clean and dry.

Most lymphedema prevention is aimed at preventing excess inflammation, in general, that can occur in the leg at risk. And there's obvious sources of increased inflammation or swelling. For example, a broken bone would cause more swelling. And, of course, everyone tries to avoid traumatic injury, but the other more subtle types of injuries are like the overuse type of injury. So if you want to do something new that you haven't done, start by doing it gradually. What we do know about exercise is that it's beneficial, and eventually, your exercise will make your body stronger and less likely to be injured.

But the fact that injuries can cause a greater demand on your lymphatic system is the reason why it is important to be strong but to do that in a slow and measured way. So, for example, if there's an activity that you enjoyed doing before you had cancer treatment, it's very likely that you can continue to do that activity. But be mindful of the time off that you had to take for your cancer treatment and work slowly back to your prior level of fitness. Physical therapists can be very helpful in guiding you back to your fitness goals and can help you treat and avoid injury.

If you're interested in starting a new strengthening program for your legs, it's important to start at a very low level and a manageable level increasing in intensity much slower than you normally would if your leg was not at risk for lymphedema. But I cannot emphasize enough it is important to stay active, lean, healthy, strong muscles, good joint motion. That all helps to circulate the blood and return the lymph fluid to your heart, and of course, if you smoke, you need to take active steps to stop smoking.

So how do we treat lymphedema if it happens? We've talked about the different stages of lymphedema, and it is not inevitable that lymphedema will gradually become worse and worse. It getting worse can be avoided by treatment. And the goal of treatment is to reduce the swelling in the leg, but then to take steps constantly to keep that swelling from returning. So treatment of lymphedema is not a curative treatment. It is management. We have not found a cure for lymphedema yet. So it's important to understand that there are 2 parts to lymphedema treatment, and they can be referred to as phase 1 and phase 2. Phase 1 treatment involves reducing the limb, getting it smaller, while phase 2 involves maintaining it.

In order to reduce the leg initially, it is necessary to apply compression, but you have to apply compression that can shrink with the leg. And that's the reason why we use compression bandages, or sometimes, I'll also call them compression wraps. Most people think of a compression wrap as an ace or elastic wrap when they think of a compression bandage. But in lymphedema treatment, we use something called a short stretch bandage, and it has no elastic in it. The short stretch wraps are used because they create a containment of a leg so that the bandage itself does not expand when the muscles contract and expand.

So what happens is when the leg muscles contract, they push up against the bandages, which don't expand, and the muscle pump squeezes the vein's lymphatic vessels more effectively. What this does is it helps moves the excess fluid up and out of the leg, and as a therapist, I can customize a short stretch wrap by including foam pieces inside that short stretch wrap that helps to mold and contour out the leg if it's gotten very swollen and help soften the tissue that might've gotten more brawny or more hard. When we add foam under a wrap, it also gives something for the leg muscles to work against. And when you move in a leg where there's foam inside it, it also kind of massages and softens the skin. And so it does help improve the skin quality, and it improves skin mobility.

Legs should move through a series of exercises after every wrap. And these exercises are called remedial. Their purpose is simple. They are done to encourage the muscles to contract against the bandage. And they're not difficult. They can be made up of simple range of motion exercises or muscle contractions.

There are other tools we use to reduce swelling along with the compression bandaging. Sometimes, we'll do a massage, which is also called manual lymphatic drainage, or MLD, and that helps mobilize swelling and soften tissue. But MLD needs to be used in conjunction with compression to be effective.  Pneumatic pumps are used similarly in phase 1, but they also should involve compression between pumping. All phase 1 therapy should include education on how to take care of your skin, how to observe for those skin changes, keep the legs moisturized yet dry, keep the skin intact, and treat any wounds right away.

Now, phase 2, which is the maintenance phase, is often more difficult than phase 1 because it involves a bit of trial and error.

Compression socks or stockings are used in phase 2 to maintain the size of a limb, but they are not necessarily superior to bandages in terms of compression. They simply allow you to go about your life without bulky compression bandages on the leg. We think of compression socks, like compression stockings, as defense, where the bandages are offense. So the bandages work to actively reduce the leg, but the compression socks maintain the smaller size. A well-fitting compression sock should be tolerable all day long. It should keep your leg the same size from morning to evening. And that takes a bit of work to find the right sock for you. And so it's important to work with a knowledgeable fitter and therapist together to figure out what works best for you. So in less severe cases of lymphedema, when you're in that stage 1 where it still reduces at night, a compression stocking during the day might be all that is needed as part of the maintenance program to keep the legs the same size. But for more stubborn cases, additional means of maintaining the reduced size might be needed. And you would know this is necessary if, in your compression sock during the day, your leg swells up and kind of creeps up by the end of the day. Sometimes, we'll add compression wrapping again at night because that will reduce the limb while you sleep with the added benefit of softening a leg that has developed some of those skin changes and thickening.

Some days are simply more demanding on a leg, and an occasional wrap at night for some people might be necessary. Wrapping at night is what we use simply because it doesn't interfere with your daytime movement. And for those patients who find that they need to wrap their leg at night fairly regularly, they do have compression devices on the market that mimic these compression bandages. It's important to work with a lymphedema therapist to help you decide what device might be best for you. And we don't wear compression socks at night simply because they are fit really tightly, and they have that more elastic compression that presses against the skin. And when your leg isn't moving, that can start to become uncomfortable. A well-wrapped leg—a good bandage should be more padded and more comfortable when somebody's asleep at night. And remember, every compression wrap is a custom fit to your leg, so it works to reduce the size of a leg better than a compression sock. And there are other tools that can be used in a phase 2 program, such as self-manual lymphatic drainage, maybe a pneumatic pump, but exercise is essential in all of your maintenance programs. So exercise is the key. Dr. Cheville, would you like to talk about how patients could find an appropriate provider to help them manage their lymphedema?

Dr. Cheville: I was just going to ask that question [laughter] because it's hard. First, Jenny did a beautiful job of kind of giving a remarkably comprehensive overview of lymphedema, and I just wanted to call out a few things that I think are key take homes and, Jenny, correct me if you disagree. But one, as Jenny said the importance of exercise. And we want to create better pump, and to do that, we use resistive exercises. So both to help the venous blood get back to the heart but also the lymphatics. Having strong muscles, and not atrophied or not collapsed muscles in your leg is important. So that's one type of exercise we would prescribe. The other is the remedial exercises that Jenny mentioned, and that's just creating a pumping action. The idea of becoming intimately aware of your leg, and if you’re starting to change your activity profile either in intensity or type, just exactly as Jenny said, keeping an eye on your leg for changes, particularly after prolonged standing or activity.

I really liked what you said about the garments being the defense and the wrapping the offense. I'm going to use that because I think that encapsulates the role of the different compression devices that we use very nicely.

And I wanted to just touch, again, on cellulitis because this is a skin infection categorized by patchy redness. Usually, it's a very discreetly demarcated area of redness, also warmth. There can be associated pain and worsening swelling. Typically, it presents after a patient has developed lymphedema but not always. At times, it's the first indicator that a patient has lymphedema. It should trigger an immediate, as Jenny said, communication to your care team, your primary provider, going to an ER because the infections can be dangerous. But also, they can cause permanent worsening of the lymphedema that can be challenging for us to reverse as practitioners. So if you have established lymphedema, this is something that should be on your radar, and I would encourage you to talk to your care team about it. And even if you don't have athlete's foot, because even minuscule amounts of fungus on your toes can create a larger portal for bacteria that normally lives on your skin to enter. So these days, I tell all my patients to use an anti-fungal powder or spray on their feet, roughly 3 times a week. I like the sprays because they get in the little crevices, and they can be less cakey and chalky than the powder.

Any other key take-homes Jenny? Do you agree with those?

Jenny Bradt: I definitely do. And I think that it is important to have—if it's possible—for you to find a therapist who's a lymphedema specialist in your area, because over the course of the time when you will be managing your leg, if there is something that is a setback, it's important to get back in touch with a therapist. They'll know you. They know your leg, and they know what works well for you. There is a designation of CLT-LANA Certified Therapist. That's the Lymphatic Association of North America. If a therapist has received an additional 135 hours of training beyond their normal physical therapy or occupational therapy degree, they can sit for that exam and get a designation of CLT-LANA. They can be occupational or physical therapists, but they would--

Dr. Cheville: Massage therapists?

Jenny Bradt: Massage therapists? I kind of prefer a medical model. We do very well having therapists who are LANA certified, but work carefully, closely, with the actual medical team of that person, so we can take care of the entire person.

Dr. Cheville: Yeah, I would agree. I think a key feature though is connecting with a good therapist. And the LANA Lymphology Association of North America website has an interactive search function that will help you identify individuals in your area. And even if you don't find somebody who's in your immediate proximity, often reaching out and contacting that person—lymphedema, it's a small community. We tend to know each other, and they very likely will be able to direct you to appropriately trained individuals, that are convenient for you.

And as a physician, hopefully, medical school has changed, but we received almost no training when I went through. This was longer ago than I'd like to think, but in lymphedema, or the lymphatic system, and what I have discovered amongst my patients over the years is they've had to become self-advocates and often educating their own care teams about their unique needs as lymphedema patients. There aren't a tremendous number of physicians specialized in lymphedema. But if you're really struggling with a condition, and feel that you're not getting appropriate local support, I would encourage you to reach out and identify a physician specialist. Which may require some travel, but it may be well worth the effort. So thank you for your attention.

Jenny Bradt: Well, thank you very much for listening, and we hope that you have many healthy and enjoyable years of exercise with your legs.

ASCO: Thank you, Dr. Cheville and Ms. Bradt. Learn more about how to prevent and manage leg lymphedema at www.cancer.net/lymphedema. And if this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play.

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 11 2019
25 mins
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Rank #3: Research Highlights from the 2018 Cancer Survivorship Symposium: Advancing Care and Research, with Timothy Gilligan, MD, FASCO

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In this podcast, Dr. Timothy Gilligan will discuss new research presented at the 2018 Cancer Survivorship Symposium: Advancing Care and Research, held February 16-17 in Orlando, Florida. This multidisciplinary meeting brings together primary care physicians, oncologists, patient advocates, and others to discuss ways to address cancer survivors’ unique concerns. 

The research discussed in this podcast includes mention of suicide. If you need help, contact the National Suicide Prevention Lifeline.

Feb 16 2018
13 mins
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Rank #4: 2018 ASCO Annual Meeting Research Round Up: Brain Tumors, Sarcomas, Pancreatic Cancer, Liver Cancer, and Kidney Cancer

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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 exiting and practice-changing news to come out of the 2018 ASCO Annual Meeting.

Jul 17 2018
30 mins
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Rank #5: 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
16 mins
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Rank #6: 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
24 mins
Play

Rank #7: 2015 ASCO Educational Book - Sexual Healing in Patients with Prostate Cancer on Hormone Therapy, with Leslie R. Schover, PhD

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In today’s podcast, Dr. Leslie Schover discusses her article, “Sexual Healing in Patients with Prostate Cancer on Hormone Therapy," from the 2015 ASCO Educational Book.

Cancer Research News
Sep 08 2015
6 mins
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Rank #8: Lymphoma Highlights from the 2017 American Society of Hematology Annual Meeting, with Michael E. Williams, MD, ScM

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In today’s podcast, Cancer.Net Associate Editor, Dr. Michael Williams will discuss some of the new research that was presented at the 2017 American Society of Hematology Annual Meeting, held December ninth through twelfth in Atlanta, Georgia.

Cancer Research News
Jan 09 2018
9 mins
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Rank #9: Alcohol and Cancer, with Noelle K. LoConte, MD

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In today’s podcast, Dr. Noelle LoConte discusses the relationship between alcohol use and cancer, and explains why ASCO has released a statement on this topic. 

Cancer Screening and Prevention
Nov 07 2017
9 mins
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Rank #10: 2018 ASCO Annual Meeting Research Round Up: Side Effects, Head and Neck Cancer, Breast Cancer, and Melanoma

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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.

Aug 02 2018
24 mins
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Rank #11: Leukemia Highlights from the 2018 American Society of Hematology, with Guillermo Garcia-Manero, MD

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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, Cancer.Net Associate Editor Dr. Guillermo Garcia-Manero will discuss some of the new research in leukemia and myelodysplastic syndromes, or MDS, that was presented at the 2018 American Society of Hematology Annual Meeting, held December first through fourth in San Diego, California.

Dr. Garcia-Manero is the Deputy Chair of Translational Research and Professor, Department of Leukemia, at The University of Texas MD Anderson Cancer Center in Houston, Texas. He is also the Chief of the Section of Myelodysplastic Syndromes at MD Anderson Cancer Center.

ASCO would like to thank Dr. Garcia-Manero for discussing this topic.

Dr. Garcia-Manero: Hello, I'm Guillermo Garcia-Manero. I am 1 of the leukemia physicians at the University of Texas MD Anderson Cancer Center, where I also serve as the chief of the section of myelodysplastic syndromes. I'm happy to do this podcast today, trying to highlight a few of the studies that were presented at ASH this past December 2018. I have to start saying that this is basically mission impossible because the good news is there were so many important presentations, with active meaning for our patients, with new drugs, and that makes the selection of these 4 presentations extremely difficult. I'm going to mainly focus on presentations on myeloid malignancies, mainly MDS and AML.

And I'm going to start with the first presentation. It's a very important phase III trial that was conducted all over the world, known as the MEDALIST trial. This study was, again, a phase III trial, was presented by Dr. List from the Moffitt Cancer Center, but it was a large effort, basically, countries all over the world. And the idea here was to test the activity of a compound known as luspatercept. This is a brand-new drug. This is an antibody that basically has the capacity to affect signaling of TGF-beta pathway in MDS. And the hypothesis is that by doing so, it may promote the capacity of the bone marrow to produce red cells and therefore improve or ameliorate anemia. As all of you know, anemia is a major complication of multiple disorders, in particular, myelodysplastic syndrome.

So the study was a randomized study. The patient population was for a specific subset of patients with myelodysplastic syndrome that are known as patients with refractory anemia with ring sideroblasts. And these patients had received already prior therapy, mainly with a growth factor, drugs like erythropoietin. The study had what they call a 2:1 randomization, meaning that for each 3 patients, 2 got into the investigational compound, luspatercept, and 1 into placebo. This drug has already been tested on prior phase I, phase II studies and is extremely safe, and we know that we can administer this compound every 21 days. The major endpoints of the study were basically to see what was the rate of transfusion independency, and that actually is measured every 8 weeks. This is criteria that investigators in the field pick. And there were other endpoints, like 12 weeks, and then also measuring increases in hemoglobin and, importantly, of course, duration of response.

This data was quite significant, and it's probably one of the first phase III trials for patients with myelodysplastic syndromes that is positive in many years. The primary endpoint, again, that was transfusion independency in the first 8 weeks, was met. So patients on the luspatercept arm had an improvement in their transfusions. The [inaudible] was close to 38% versus 13% for those patients who were on placebo, and this was highly significant. Most importantly, when the investigators looked at the duration of response, this was also significantly in favor for those patients that received luspatercept. So, in other words, not only was there higher response rate with this new agent, the response is also longer. So that is very important. And then, as I mentioned earlier, in general, these compounds are extremely well tolerated without a major, significant toxicity issue.

So we are excited about these results because it may be—of course, this drug is not yet approved by the FDA. But the expectation will be that this would be an excellent compound for this first subset of patients with myelodysplastic syndrome. But there is already an ongoing phase III trial for patients with MDS, low risk, that have not received any prior therapy. So we're moving into front line with this particular compound. And there was also some very interesting data in patients with thalassemia, that was also positive. So it has implications beyond myelodysplastic syndrome.

I am not sure what the future development of this compound will be, but I think it's going to have multiple applications in solid tumor malignancies, potentially as an adjunct in patients receiving induction chemotherapy for acute leukemia. And there are also some ongoing clinical trials in myelofibrosis. So that was very exciting.

The second study that I would like to highlight is a study known as TELESTO, and this is basically a clinical trial where patients with low-risk MDS were randomized to received iron chelation with a drug known as deferasirox or not. Why this is important is because, over a decade ago, this compound, deferasirox, was approved for patients with a number of disorders, including myelodysplastic syndrome, that had evidence of iron overload. So in myelodysplastic syndrome, because of the need for red cell transfusions, it is not uncommon that patients will accumulate iron. And that in itself can result in complications for the patients, such as liver damage, heart damage, etc. So, despite the fact that this drug was approved, the way it was approved was on non-randomized clinical trials. So we never actually knew for a decade whether there was true benefit to this compound or intervention in patients with lower risk disease and anemia with iron overload. And why this is important to know is because this drug, although it's an oral compound, it can have some side effects that can be significant, and there's also a cost issue with this approach for our patients.

The study was actually designed many years ago. I was part of the group that designed this clinical trial. And originally, it was designed to test whether iron chelation was going to result or not only in improvement in overall survival. And the original design was going to involve, I believe, over 800 patients. When the study was opened, it became clear that this was not going to be feasible because this drug had already been kind of embraced by the community as a standard of care. So the study actually was then modified with the advice of the authorities, mainly the FDA, and it became this study where the main endpoint was event-free survival.

Similar to the study that I discussed earlier, this had 2:1 randomization, and patients were randomized into deferasirox or placebo. And because these are tablets, that was quite easy to do. Again, the main objective was to evaluate event-free survival, but we were also interested in looking at overall survival and other biomarkers like ferritin levels, [inflammatory?] responses, and some of the comorbidities that are associated with iron chelation.

The study, again, was positive. And what these investigators—and this data was presented by Dr. Angelucci, who is from Italy—clearly indicated that there was a longer event-free survival for those patients that were treated with the iron chelation drug deferasirox compared to those that do not. And, indeed, actually, the risk reduction was almost 37%. So this data is important because it establishes a potential role for iron chelation in our patients. Now, there is a major limitation, of course, of this drug. That is, unfortunately, we cannot really measure or state that the overall survival benefit was clearly achieved by this compound. That said, actually, there was an improvement also in overall survival for patients treated with this compound, but the hazard ratio was significantly higher than that for event-free survival. And again, this study is likely not powerful enough to really clearly demonstrate an improvement in survival, although it clearly demonstrated this other event-free survival improvement. The other limitation of the trial is that we don't know why the event-free survival is better. That is something that is not clear from this data analysis. But the reality is that, in my mind, this is the only and probably will never be repeated randomized phase III trial of iron chelation. And I think it shows that this is associated with a clinical benefit for our patients.

The next study that I would like to present is a study for patients with acute myelogenous leukemia, and this was a study presented by Dr. Maiti from Houston. And it's one of the multiple studies that looked at the addition of venetoclax to drugs like decitabine or azacitidine for patients with acute myelogenous leukemia. As many of you know, during the meeting, this new agent venetoclax, or ABT-199, was approved for patients with AML. And this was based on a number of clinical trials that had been done at multiple centers. So there were multiple presentations, but I can tell you that this was one of the most exciting topics of the ASH meeting, the addition of ABT-199, or venetoclax, to either decitabine or azacitidine for patients with AML.

So venetoclax, or ABT-199, is a drug that modifies apoptosis. Basically, the idea is that enhances cell death in these leukemia cells. And data from Dr. Konopleva and other investigators have indicated that there is synergism between venetoclax and the hypomethylating agent, either azacitidine or decitabine. And there are a number of studies showing actually very high response rate with these compounds.

But I highlighted this study because it looks like a different alternative schedule. Here, the investigators gave 10 days of decitabine with venetoclax for basically every day of the month, and they reported an overall response rate that was over 90%. And what I think is striking, that half of these patients with acute myelogenous leukemia achieved what we call minimal residual disease status. So they were MRD-negative with this therapy, indicating that there was eradication of the leukemia clone. The follow-up on this study was short, but the survival actually was close to over 95%. So we all believe that this very exciting data, whether you administer this with 10 days of decitabine or 5 days of decitabine or with azacitidine. And it's likely now becoming the standard of care for most patients that are receiving a hypomethylating agent for acute myelogenous leukemia. So this is extremely good news for our patients, and it will open up to multiple other combinations.

And to finish, I will bring one of the last presentations in myelodysplastic syndrome. But I think that this is a topic that has also implications for other myeloid malignancies. So this is Abstract Number 465, and I had the opportunity to present this poster. So this is a study performed mostly in Houston, where we combined azacitidine with drugs that are known as immune checkpoint inhibitors, drugs like nivolumab or ipilimumab. The hypothesis for this is that it turns out that the leukemia cell or the MDS cell express molecules like PD-1, CTLA-4 on their surface. And similar to what you see in solid tumors, where these compounds are extremely effective, for instance, for melanoma and other solid tumors, it is possible that these compounds could also have activity in these myeloid diseases. So we have tested these in a clinical trial, combining these immune checkpoint inhibitors with azacitidine. And we have tested this in patients with high-risk MDS that have not received prior therapy or in patients with relapsed refractory disease that already have failed a hypomethylating agent like azacitidine.

The study actually has accrued almost 100 patients, and we believe that this data is very important. So what we first found was that the combination in the front line of immune checkpoint inhibitor, such as nivo or ipilimumab with azacitidine, is associated with a very high response rate. So the overall response rate, for instance, with azacitidine-nivolumab was over 70%, and it was over 60% with AZA-ipilimumab. But that's not what I think is important from this presentation. What was important was that the duration of response, particularly in the combination of azacitidine and ipilimumab with a follow-up on this clinical trial of around 20 months—this is quite a long number—had not been reached. And we have not had data like these in any of the prior studies that we have done with doublets, for instance, with HDAC inhibitors or other compounds. Now, there is a limitation of this, that the incorporation of this immune checkpoint can be toxic. This is something that solid tumor oncologists are familiar with, but it's a little bit new for us. It can cause things like pneumonitis—this is lung inflammation—colitis, skin rash. These sometimes are difficult to treat, so this is not ready for standard-of-care type of approach. But I think it's going to be an important part of the armamentarium for our patients with myelodysplastic syndrome.

So with that, I would like to conclude, perhaps, do a very quick summary. I presented to you 4, what I think, very important presentations. The first one was a new drug for MDS called luspatercept. This may be very important to treat anemia, and we are excited about future development of these compounds. The second presentation was about iron chelation in MDS. This has been an area of huge debate in our field, and this data I think supports further the use of these types of compounds for our patients with iron accumulation. Third, the data with ABT-199, or venetoclax, with decitabine in AML is really important. And I think it's now established as the standard of care for those patients not fit for chemotherapy. And finally, this data with immune checkpoint inhibitors indicates that there may be an important role for these compounds also in MDS, and other presentations at the ASH meeting in AML suggested kind of the same. And with that, I want to thank you for this opportunity and your time.

ASCO: Thank you, Dr. Garcia-Manero. Learn more about leukemia and MDS 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.

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.

Feb 19 2019
15 mins
Play

Rank #12: Social Media for People With Cancer, with Merry Jennifer Markham, MD, and Danielle Gentile, PhD

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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.

Monika Sharda: Hello. I'm Monika Sharda, an editor on the Cancer.Net team and your host for today's podcast. In this episode, I will be talking with two guests about how cancer patients use social media. Our first guest, Dr. Merry Jennifer Markham is a hematologist at the University of Florida in Gainesville. Welcome, Dr. Markham.

Dr. Markham: Hi. Good morning. Thanks for having me.

Monika Sharda: We also have with us Dr. Danielle Gentile, who is a researcher at Levine Cancer Institute in Charlotte, North Carolina. Hi Dr. Gentile.

Dr. Gentile: Hi Monika. Thank you for having us this morning.

Monika Sharda: My pleasure. Drs. Markham and Gentile recently published a study in the Journal of Oncology Practice that describes potential benefits and drawbacks of people with cancer using social media. Today, I'm going to discuss with them some of the findings from their study, as well as what people with cancer should know about using social media and how it can provide support.

First off, I want to know what sparked your interest in studying social media and its use for people with cancer. Dr. Markham, let's start with you.

Dr. Markham: Sure. So I have had an interest in social media for several years. And some of that stems from my own personal and professional use of social media, primarily platforms like Twitter. And one thing that I've noticed is that I've connected on Twitter with a lot of patient advocates and colleagues and sometimes people who identify themselves as patients, as well. And there's a lot of searching for information that happens, I think, on social media. So that has really stemmed my interest in exploring it further as a potential tool for patients, as well as researchers and oncologists and other health professionals, to take advantage of what's out there.

Monika Sharda: And what about you, Dr. Gentile?

Dr. Gentile: I'll echo many of the things that Dr. Markham shared. And there's ways to find so much information through social media, things that a person may not even be directly seeking. They can come across things indirectly and learn that way. So it's quite interesting to see how people are able to make connections across the country and across the world with people who are in similar situations that they are. And social media is a way to gain some social support in ways that may not be possible in person. So if a person is not feeling well from their cancer diagnosis or treatments, they can reach out online. And through Twitter or Facebook, they're able to meet others who can share in the experience with them.

Monika Sharda: So what I took away from your study is that social media can sort of be a double-edged sword. There's potential benefits for patients, but then there are also potential drawbacks. So let's start by talking about some of the pros. How can social media be helpful to patients?

Dr. Gentile: So there's a few ways that patients can use social media to their benefit. And one is that it's great for engagement and empowerment. So it provides a platform for patients to talk about their diagnoses, to search for information, digest what is happening in the world of cancer research as well. And through all of that information and connection with others, it can provide psychosocial support too. So those who are able to disclose some of their thoughts and their feelings and meet with others who share similar stories and are in the same boat, it can be helpful for them to make those connections.

Dr. Markham: I think that that source of support is really one of the invaluable pros to social media. I am a medical oncologist and see patients who have gynecologic cancers. And we live in an area where there's not a lot of in-person access to support groups. I am never offended when my patients come to me with things that they've read on the internet because, unfortunately, it really is a resource that a lot of people rely on. And I think that when my patients are able to connect on social media to other patients with similar diagnoses or similar health experiences, it really allows me to have a better conversation with that patient in the exam room. She can bring me information about what she's read or what she's heard from a friend of hers across the country. And then we can have a conversation and I can take care of her better knowing what she knows.

Dr. Gentile: So another pro coming from me from a research perspective is that social media can be a valuable recruitment tool for researchers who are looking for demographics of patients that are pretty specific. So if you imagine a rare cancer diagnosis, it can be hard to find those patients in any small geographic area. But by using social media, those groups can cluster online. So it could be a Facebook support group for a certain diagnosis and a researcher could post on that group and ask if anyone is interested in a potential research study or a trial. And so it's a way of connecting patients to opportunities to participate in research that their home oncologist and their support team may not be aware of.

Monika Sharda: Absolutely. And what are some of the cons? What should patients be cautious about when using social media?

Dr. Markham: I think one of the real risks of social media is misinformation. It's very easy for false information or altered information to spread widely on social media, either Twitter or Facebook or otherwise. And sometimes it's hard for people to distinguish what's the good information, what's a quality piece of research, or a true statement about health that can be trusted, versus what is myth and what's not to be trusted. So distinguishing between good information and reliable health information is certainly one of the risks that I do worry about with, not just patients, but with their caregivers, and, truthfully, health professionals as well.

Dr. Gentile: And another, with all of that information that patients can find online, is they're trying to decipher what's good information, what's misinformation, and what to act on. It can result in what we call information overload. And that's when a person has gathered so much information that they become overwhelmed by the amount of the information and they're not sure how to act on it. So it can lead to this feeling of paralysis or being stuck. And something that we recommend for that is always talking with the clinician. Like Dr. Markham said, she's not offended when her patients bring her information they've learned online. And that's one of the best resources to determine if information is worthy or not.

And I'll share another potential con for social media and that is privacy concerns. So pretty much anything that goes onto the internet is for public use. And folks will think about their privacy filters. Do they want only their connections to see it? Do they want it to be widely, publicly available? But one can never be sure, even with those privacy filters, that their information won't go somewhere they don't intend it to. So if a person posts on Twitter in a private group thing that they have a certain diagnosis, it can never be for certain that someone in their daily social connections might see that. So anything a person posts online, I would advise make sure that's something you feel comfortable with everyone knowing.

Monika Sharda: Going back to the idea of misinformation for a minute, you mentioned one way for it to help patients differentiate between what's worthy information and isn't is, of course, to talk with your oncologist about it. Talk with your healthcare team. Are there any other tips you can provide patients with how they can differentiate between reliable and unreliable information?

Dr. Markham: So I think looking for the source of information can be helpful. Information that's put out by American Cancer Society or by ASCO or Cancer.Net, for example, is vetted by clinicians and physicians who, I think, lend some support to that information being trustworthy. There are other sources, such as the National Cancer Institute that shares information regularly on social media. I think it's when there's an article in a non-medical journal or not one of these professional organizations that is sometimes hard to see today whether it's true or not true. And I think in those situations, it really is advisable for patients to take that information to their doctor, to ask more questions about it. I've encouraged my patients to go to certain resources online for information. And I've also encouraged them to bring me information that they want to know more about. And it's not infrequent that I have my patients come to me with things that they've seen online, whether on social media or otherwise, and it allows us to have a good conversation about what's true and what's myth.

Dr. Gentile: It can also be important to think, "What is the motivation behind whomever has posted the certain piece of information?" So if it's a reliable source, like ASCO or Dr. Markham is posting it, she is a hematologist, she is likely doing that because she wants to share the information for educational purposes and to help the lives of her patients. But there are plenty on social media who have profit motives for sharing information. So it might be some type of miracle cure where taking this product would completely take care of the cancer. And something my mom told me, is true in this situation: if it sounds too good to be true, it is. So be cautious and think about why a person might post something on social media.

Monika Sharda: Those are some really great tips. And Dr. Markham, I think it's really great how you encourage your patients to talk with you about what they've read, what they've seen on social media and really encourage that conversation instead of them trying to figure out on their own whether the information that they're seeing is worthy, is reliable. What would you say is the most effective way for patients to use social media to communicate?

Dr. Markham: So the most effective way, that's a bit of a hard question because I think there's probably multiple ways for patients to use social media. I think one reason that I like Facebook for health information, actually, is because there are a variety of groups that are closed and private that patients may discover for health information and, primarily, for support. So I think those are sometimes opportunities. The challenge of those, of course, is is there reliable information being shared. Some groups have healthcare moderators within them and some do not. So that is one of the risks of participating in a group. I think if a patient feels uncomfortable or overwhelmed, they should remove themselves from that situation.

I think on Twitter, there's an opportunity to participate around hashtags. Hashtags are terms that you can plug into Twitter using the hashtag or pound sign with a phrase behind it, such as #breastcancer. And that is a good way of sort of filtering out information that's targeted to that type of health problem. And there's a lot of communities, actually, in the Twitter space built around these hashtags for healthcare where there are routine chats that may happen. Breast cancer actually has a good advocacy group on Twitter centered around the #bcsm, which stands for breast cancer social media. And there are physicians within that community and patient advocates and patients themselves. And it's, I think, a good starting point for a patient who may be on Twitter and wants to connect with others who have similar interests or similar desires to connect.

Dr. Gentile: And I think it's also important for any patient who wants to access social media in relation to their cancer diagnosis to spend some time before they enter these platforms and ask themselves, "What are they hoping to get out of the experience?" Is their primary motivation to get social support and meet others in social support groups, or is it looking for new, reliable information? Is it a mix of the two? And then, again, checking in with oneself periodically and asking, "Am I getting what I need, what I was intending to get?" For example, Dr. Markham was saying that if a person becomes uncomfortable or they find the situation overwhelming within social media, fielding many messages, then they can just remove themselves. And one should really go at their own pace and do what makes them feel comfortable and beneficial. There's no real obligation to respond to folks if you're not finding it to be beneficial.

Monika Sharda: For someone that's not too comfortable with social media or has trouble finding relevant hashtags or Facebook groups, do you have any tips for them on how they can seek out these groups and what the relevant hashtags are for them?

Dr. Gentile: Sure. So I'd recommend that a patient get started with some platforms that they know are reliable, valid, good information sources. So, for example, Dr. Markham mentioned the #bcsm, breast cancer social media. And just starting with one hashtag or one support group on Facebook can lead a person down the line to other places to explore. So starting small and then branching out, I think, would be helpful for most cancer patients.

Dr. Markham: ASCO has some good resources, both for patients and for caregivers, I believe. There's something called Social Media 101 for Patients that ASCO has published. So that's a good starting point for people who may want to jump into social media period. Also, I think patients who are interested in finding groups may be able to reach out to their oncologist or other physicians to inquire if those physicians know of reputable groups that they could join.

What I find, though, is that a lot of the networking that my patients experience in social media has come from their online sort of word of mouth, which is a little harder to know about. Our social worker in my own clinic is sort of compiling a list of places where patients tend to congregate online so that she can point other patients in the right direction. But I think we still have a lot of work to do in this area to help really guide our patients well.

Monika Sharda: And that actually leads me to my next and final question. I was going to ask you to share some resources for patients to learn more about using social media safely and effectively. So you've already mentioned ASCO and the resources they have and also, talking to your healthcare team and your oncologist. Do you have any other resources that you can share?

Dr. Gentile: So I think those are probably two of the most important. I know that I have had patients who have reached out to organizations on social media, such as American Cancer Society and, probably, Cancer.Net may have had this experience as well, asking for information from those groups on who to recommend and how to approach things. So I think that Cancer.Net certainly has lots of good resources. But, really, I think ultimately, just conferring with a physician at the end of the day, to make sure that the space that is being found and using social media in a safe way as a patient, can be a discussion with the physician and patient together.

Monika Sharda: Right. Well, that's all of the questions I have. Is there anything that, perhaps, we didn't touch on already that you'd like to talk about?

Dr. Gentile: I'd like to say that it's going to be different for every patient or every loved one who is caring for someone with cancer, when it comes to social media. And to feel okay with taking it at your own pace. And if you find that you have a piece of information that you are unsure about, the take-home message is to share that with your healthcare team and get that checked out. And to not make big decisions on how you're going to care for yourself or your loved one solely based on a piece of information from social media.

Dr. Markham: I think that's an excellent point. And the only other thing I would add is that social media can be scary for those who are just diving in, and I don't think it necessarily has to be. It's just a matter of taking it slow, at your own pace, as Dr. Gentile said. And just testing the waters.

Monika Sharda: That's really great advice. Drs. Markham and Gentile, you've shared a lot of great tips with our listeners on using social media and provided additional resources where they can learn more about the topic. It's been a pleasure having you on this podcast. Thank you so much for joining us today.

Dr. Markham: Thank you so much for having us.

Dr. Gentile: It's been a great pleasure for me too.

ASCO: Thank you, Dr. Markham and Dr. Gentile. Find more resources on using social media 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.

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.

Mar 05 2019
19 mins
Play

Rank #13: Pain and Opioids in Cancer Care: Benefits, Risks, and Alternatives, with Judith A. Paice, PhD, RN

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In today’s podcast, Dr. Judith Paice discusses options for managing cancer-related pain, including opioid medications, and medication-free alternatives. She also discusses the use of cannabinoids, which are derived from marijuana, including recent clinical research and associated risks and barriers. 

Side Effects
Aug 29 2017
11 mins
Play

Rank #14: 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
15 mins
Play

Rank #15: Patient-Centered Care, with Meg Gaines, JD, LLM

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This podcast features an interview with Martha "Meg" Gaines, Distinguished Clinical Professor of Law at the University of Wisconsin-Madison and Director of the Center for Patient Partnerships. She shares her personal experience with cancer and explains how it led her to advocate for others with cancer and found the Center for Patient Partnerships. She also discusses patient-centered care, and shares tips for patient advocates.

Jul 19 2018
14 mins
Play

Rank #16: 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
23 mins
Play

Rank #17: Improving Communication Between Patients and Health Care Providers, with Timothy Gilligan, MD, FASCO, and Liz Salmi

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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 today’s podcast, Dr. Timothy Gilligan and Liz Salmi will discuss their article “Patient-Clinician Communication Is a Joint Creation: Working Together Toward Well-Being,” from the 2018 ASCO Educational Book. They cover several ways people with cancer and members of their health care team can work together in order to improve their communication, including a study on sharing clinical notes with patients, a recent guideline from ASCO on physician-patient communication, ways to address religion and spirituality, and tips for patients.

Dr. Gilligan is an Associate Professor and Medical Oncologist at the Cleveland Clinic Taussig Cancer Center. Ms. Salmi is a brain tumor survivor, and Senior Strategist in Outreach and Communications for OpenNotes.

Published annually, the Educational Book is a collection of articles written by ASCO Annual Meeting speakers and oncology experts. Each volume highlights the most compelling research and developments across the multidisciplinary fields of oncology.

ASCO would like to thank Dr. Gilligan and Ms. Salmi for discussing this topic.

Dr. Gilligan: Hello, my name is Dr. Timothy Gilligan from the Cleveland Clinic. I'm joined today by Liz Salmi of OpenNotes and the Beth Israel Deaconess Medical Center. In this podcast, we will be sharing some key points from our 2018 ASCO Educational Book article titled “Patient-Clinician Communication Is a Joint Creation: Working Together Toward Well-Being.” I would also note that Dr. Andrea Enzinger from Dana-Farber was an author on that.

So, Liz, we were going to start with talking about your piece on this, your work with OpenNotes. And for those who haven't heard of this, the idea is making progress notes openly available to patients so they can read the progress notes about their medical care. Can you talk a little bit more about what OpenNotes is and what's at stake here?

Liz Salmi: Sure. Absolutely. Thanks for that intro. And I just want to say my role at OpenNotes—I do outreach and communication work, but, also, I think it's important for the audience to know that I am also a patient. I'm a person living with a malignant brain tumor or brain cancer. And I'm now a 10-year survivor, but I'm still living with active disease. So what I'm talking about today is not just part of my job, but it's also very personal to me. And so what you just kind of gave me a lead-in on, is explaining what OpenNotes is, but I do want to repeat a little bit about that. So OpenNotes is now a national movement that stems from real medical research, and it's a movement dedicated to making healthcare more open and transparent by giving people—or patients—access to their doctors' notes via existing secure online patient portals.

And when I say that, I want to make it clear that OpenNotes is not a product, or it's not a piece of software. It's more of just a concept of let's give patients full access to their medical records. And when we talk about OpenNotes, a lot of patients will say, "Well, what is a doctor's note?" Right now, I, as a person, can login to my digital online portal to email with my doctor, or, say, set up appointments, or order prescription refills. And sometimes, after a visit I can see a visit summary of a little bit of what transpired at my visit with my doctor. But what I don't see is my clinical notes.

Now, clinical notes, a lot of people and patients don't realize that after every clinical visit with a doctor, they go back to their office and write up these really detailed notes of everything that transpired during the visit. But most patients, about 93% of the US population, don't have access to this information. And it's a bummer because that information is so detailed. And as a person living with cancer, I'm kind of dealing with something that's emotional and overwhelming, and most people can't remember everything that their doctor says. And most doctors keep track of all of this in their clinical notes.

And OpenNotes, as a research project, was looking into what would happen if we gave people or patients easy access to those clinical notes that the doctors write. Would they understand those notes? Would they get some sort of benefit or value out of it? What would doctors think about that? And so I want to talk about what that original study is, and I'll hopefully try to do it quickly. But OpenNotes started as this research project. It was conducted in 2010, the first project, and it has now been replicated at multiple sites around the country. The original research was done with over 100 primary care doctors and 20,000 patients. And we tested this concept of sharing notes at 3 sites, at the Beth Israel Deaconess Medical Center in Boston, at Geisinger Health in Pennsylvania, and at Harborview Medical Center in Seattle.

And at the beginning of the project, they asked all the clinicians who'd be sharing their notes, "What do you think's going to happen?" And the doctors thought, "Gosh, we write these notes at such a high level because it's a communications tool with our other colleagues. And we don't think our patients are going to really understand what we're writing. And we're also concerned that patients might be afraid of what they read because there's all kinds of stuff we capture in there." And they also surveyed those patients. Before they received their notes, they surveyed them and said, "What do you think's going to happen? You're going to now read your notes for the next year. What do you think?" And patients, even people like me, were like, "I don't know what to expect. I've never seen this type of information before."

So fast-forward to a year later, and what they found was that during that year about 80% of patients read a note, and 75% of patients reported benefits. They felt like, "Wow, if I can read my doctor's notes, I feel more engaged in my care. I better understand why certain medications were prescribed to me. I felt like I had more control over my care." Sharing the notes improved the doctor-patient relationship. 99% of patients felt better or the same after reading just one of their doctor's notes. They felt they could trust their doctors more. And, just like regular people, sometimes doctors make mistakes. And sometimes those mistakes would transfer to their clinical notes, and patients, when they're reading those notes, were able to point out errors. For example, the doctor might write, "There's a problem with your left knee." And the patient will say, "Actually, I was talking about my right knee." So there was this opportunity for a little bit of quality control.

Dr. Gilligan: Well, thank you. So you've outlined, obviously, some of the benefits to patients in terms of direct access to information, the opportunity to correct mistakes, the chance to feel more empowered. I'm curious. Often, we hear from clinicians fears that this is going to generate a lot more phone calls or problems, or patients will get upset. Can you talk just a little bit more about what the research has shown in terms of what has actually happened when this has been turned on, so to speak?

Liz Salmi: Absolutely. So we've learned a lot. They're concerned that by sharing their notes, it's going to increase that doctor or other clinician's workflow, meaning if a patient reads a note and anything about it is unclear, or maybe there's a word and phrase they don't know, it's going to trigger an email or a phone call back to the doctor. So mainly, the concern is workflow. And we've seen—and it continues to show—that workflow does not increase. W

hy is that? Well, often, a patient will go to a visit, leave that doctor's visit, and then later go, "Oh, my gosh. I can't remember what my doctor said." If they don't have access to their notes, that triggers an email or maybe a phone call saying, "Oh, hey, Doc. I can't remember. Did you tell me to do this or that?" or, "How many times am I supposed to take this medication?" or, "How many exercises do I need to do each week?" or, "What was that thing you said?" With OpenNotes, patients can actually go back to the doctor's notes, the exact record of that interaction, and refer to the note itself. So that decreases the need for another email or another phone call.

Occasionally, a patient might read a note and have a question that the note triggers. So then they might follow up with a question through email or a phone call. So the 2 kind of cancel each other out, and, overall, you don't see an increase in workflow.

Also, they’re worries that most doctors have in advance of sharing notes. "Oh, my gosh.  I think my patient is going to read what I write, and they're going to get stressed out by it." But that never happens. And what is written in a medical record and in a note is what the doctor actually says to the patient. So there shouldn't be any new information, necessarily, in the note. An interesting thing to think about is that after that original study, all the doctors who shared their notes after that entire year were allowed to stop sharing their notes, but not a single 1 did. They were like, "Oh. This is working out for me. My patients seem to like it. So I'll keep going."

Dr. Gilligan: So I want to use that as a segue because we have two other subjects we need to cover in this podcast. Both in the article and in the session we did, we talked about the new ASCO patient-clinician communication guidelines, the first guideline that's been published. And that was published late 2017.

The guideline was broken down into 9 key areas that we thought were important. One was just core communication skills. How do you have the conversation in a better way?

One thing that's often unappreciated is that a lot of Americans have low health literacy. They have low numeracy. If we say to a patient, "There's a 30% chance of this or that," that may sound very obvious to us what it means, but it often is misinterpreted. And even lay persons, what we might consider average or normal numeracy or literacy, don't take in the numbers they get from healthcare professionals as fluently as they think they do, and there are better and worse ways that have been studied of doing that, and we talk about that.

Cost of care is a new issue. Bankruptcy from healthcare is a large problem in this country. There's a lot of unaffordable drugs out there, so how to talk about that is an issue that comes up in it.

Underserved population is a concern that we address, whether it's racial or ethnic minorities or other underserved populations. The LGBT community and their healthcare needs is increasingly recognized, and ways in which they encounter challenges in the healthcare setting a problem, so we talk about that.

And then lastly, the issue of how do we train people to get better? There's been a lot of research in how people improve in communication, and I think the big take home from that is that communication is a motor skill. It's like learning how to play a sport or a musical instrument, and the way people get better at it is by practicing it and then getting feedback so that they can improve.

And then the last piece that I really wanted to get your thoughts about was how do we talk about spirituality for patients with patients? We know that from studies of patients and surveys that the majority of patients think spirituality, whether or not that's formal religion, but spirituality in general, is important to them in coping with serious illness, and yet it's something that many providers feel unprepared or unskilled at in terms of bringing up. So in a sense, this links in with the former topic of key communication skills. I'm curious your thoughts, as a patient, what you think about the issue of spirituality and how it can be helpful to patients going through a difficult time.

Liz Salmi: Yeah, no, absolutely. And thanks for clarifying. There's formal religion and then there's just kind of general spirituality, kind of a vague aspect or a way of looking at things. And, I think, as a person who-- I don't attend church, but I do think about how I view my place in the world and as that relates to my cancer experience is they kind of go hand-in-hand.

And when I was first diagnosed, realized I had a brain tumor, and then I had a brain surgery, and I'm laying in the hospital 24 hours later, and a chaplain walked into the room and introduced himself and said, "Hey, I'm the hospital chaplain. And I just want to let you know that I'm here to talk to you." They are basically offering their support. But as a new patient and someone who's never been in the hospital before, I had no idea what the role of the chaplain was. And I told the person. I was like, "Yeah, I don't want to talk to you right now. What are you doing here?"

And they also scared me. The presence of a chaplain, I had only seen from TV that if a religious person came into a hospital room it meant somebody was dying. And I was like, "I just had brain surgery 24 hours ago. They're sending in a religious person to see me. Does that mean I'm dying?" So it freaked me out, and I told the person, "No, I don't want to see you. Please leave." And then when the nurse came in to check on me, I said, "What was that all about?" and the nurse says, "Oh, if you don't want a chaplain to come see you, I can make a note to not have them come see you again." I said, "Yeah, please do that."

So, actually, in my medical record, someone made a note in my inpatient notes, "Patient refuses chaplaincy services." And it wasn't until 2 years ago, so like 8 years after diagnosis and that first brain surgery that I learned a chaplain is non-denominational. They're there just talking about psychosocial, spiritual issues, that it has nothing to do with a particular religion at all. They're just there to help. And I think it's a bummer and a disservice that I didn't find out until eight years later when, really, I probably could have benefited from having someone to talk to from that perspective.

Dr. Gilligan: I think the promise here is that if we feel confident that we have the tools to do this, and we know how to have the conversations, and then we start having them, we'll be taking better care of our patients because they're telling us in surveys over and over again that this is important to them, and it would help them if they could talk about it. But it has to be done in a skilled way. And as your story, Liz, tells, if it's not done that way, then it can be unhelpful. It reminds me of Rana Awdish in her book In Shock talks about story where she wakes up in the ICU, and she's getting last rites. And that's not really the way you want to be introduced to a priest [laughter].

Liz Salmi: No way. That's wild.

Dr. Gilligan: It was kind of shocking to her at the time. Obviously, she survived to write about it, thank God.

Liz Salmi:  Well, you talk about these communication guidelines, which are for doctors to help them better understand how to communicate well with patients, but I was just curious if you have a couple tips for the listeners who, mainly, are patients for this podcast. What can patients do to help ensure smooth communication with our healthcare team? Do you have any tips for us if we want to kind of take control of situation a little bit?

Dr. Gilligan: Yeah, no, that's a great question. So 1 of the things I find interesting about that is that in the early research on the impact of communication on patient medical outcomes, it was documented very early that outcomes in managing high blood pressure, managing diabetes, other hard medical outcomes, not the more patient-satisfaction, softer stuff-- that hard outcomes improved if you either taught clinicians to communicate better or taught patients to communicate better. Either one has a positive impact on healthcare, so it's very appropriate to ask. The reason we focus on training clinicians is there are many fewer clinicians than there are patients out there. Training all the patients in the world would be a lot of people to train.

I think the most important thing is to come organized, to have it very clear what your priorities are, and what you're hoping to accomplish, and to try to lay that out early in the appointment. And it's helpful for us clinicians to know, but it's also helpful to advocate for yourself if you come in with a clear sense of what your goals are and what you're hoping to get out of the encounter.

I think the other thing I would say is it's really helpful to bring someone with you. I think if I'm ever in the hospital, I would want a family member there. And if I ever have a family member in the hospital, I'm going to be there, too, because in the modern healthcare system you need to advocate for yourself. And so I think being prepared and organized is one way you can advocate for yourself. Bringing someone with you can help, as well.

The last thing I would say is the model of communication skills that we teach is really built around building stronger relationships between clinicians and patients. And I think that, on both sides, it's a 2-way street, that relationship. If we both pay attention to the fact that we will work together much more effectively if we have a strong relationship, then we can try to communicate with each other in a way that helps build that up.

Illness is stressful. People get upset. They get angry, and all that is natural. But the more we can remember that, in the end, we're on the same team, we're kind of rolling the same direction. I usually find myself saying this to clinicians to try to avoid getting into unnecessary conflict with patients. But I think also, too, on the patient side. So those would be the 3 things I would really think about: being organized, bringing a family member with you when possible—I realize it's not always possible—and then paying attention to the nature of the relationship and attending to the relationship, not just the work that you're trying to get done. There's certainly more I could say, but it's a big subject.

Liz Salmi: Yeah, no, absolutely. And thank you for that. It was really helpful. I know, from an OpenNotes perspective, we often realize that access to information also helps ensure smooth communication. And when doctors and patients are on the same page and able to look at some of the same information, a patient's level of understanding increases. And it helps us make better decisions overall.

Dr. Gilligan: I agree, 1 of the things I like about giving patients more access to information is 1 of the things I, in a sense, challenge patients to do is to take more ownership over their own care. They should know what medications they're on, and they should know why they're on them, and they should know why they take them. I don't say that in a critical sense, but just if it's me, and someone has me on medication, I want to know why, and I want to know which drugs I'm taking. And keeping track of that, I think, taking more ownership over that, and really knowing your medical history to the best extent that you can helps you get better care in our system.

Liz Salmi: Yeah. Absolutely. High five on that one.

Dr. Gilligan: Well, it's been great talking to you again, and--

Liz Salmi: Same. Yeah, and thank you. It was a pleasure to get to write this article with you in the ASCO Educational Book, which, I believe, anyone can read at ASCO.org/edbook.

Dr. Gilligan: That's right. That's right. So look it up, take a look. We hope that you enjoy it. Thank you for listening to our podcast.

ASCO: Thank you Dr. Gilligan and Ms. Salmi. Please visit ASCO.org/edbook to read the full article. And if this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play.

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.

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Aug 14 2018
20 mins
Play

Rank #18: Understanding “Biosimilars,” with Gary H. Lyman, MD, MPH, FASCO, FRCP

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Research into new forms of biologic therapy, such as immunotherapy or targeted therapy, have made dramatic advances in treating and managing cancer, but these therapies can be very expensive. You may be familiar with generic drugs, which are identical copies of brand-name drugs, and are often much cheaper. However, the manufacturing process for biologic therapies is so complex, it is not possible for a different manufacturer to make an identical copy. 

In this podcast, Dr. Gary Lyman discusses biosimilar agents, which are similar, but not identical, copies of these drugs. Dr. Lyman discusses some of the differences in manufacturing biosimilar agents, the criteria that are used to ensure they are as effective as the original drug, and some of the ways that biosimilars can help reduce the cost of cancer care.

Feb 14 2018
19 mins
Play

Rank #19: Research Highlights from the 2017 San Antonio Breast Cancer Symposium, with Erica Mayer, MD, MPH

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In today’s podcast, we’ll discuss some of the new research that was presented at the 2017 San Antonio Breast Cancer Symposium, held December fifth through ninth in San Antonio, Texas. This podcast will be led by Cancer.Net Associate Editor, Dr. Erica Mayer. 

Jan 25 2018
11 mins
Play

Rank #20: Lymphoma Highlights from the 2018 American Society of Hematology, with Michael E. Williams, MD, ScM

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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, Cancer.Net Associate Editor Dr. Michael Williams will discuss some of the new research in lymphoma that was presented at the 2018 American Society of Hematology Annual Meeting, held December first through fourth in San Diego, California. Dr. Williams is the Chief of the Hematology/Oncology Division and Director of the Hematologic Malignancies Program at the UVA Cancer Center, and Byrd S. Leavell Professor of Medicine and Professor of Pathology at the University of Virginia School of Medicine.

ASCO would like to thank Dr. Williams for discussing this topic.

Dr. Williams: Hello. This is Michael Williams. I'm a professor at the University of Virginia Health System in Charlottesville, Virginia, and I'm reporting today on some exciting advances in lymphoma that were presented at the Annual Meeting of the American Society of Hematology, which was held in San Diego, California in early December 2018. Well, there were a number of areas of lymphoma that had important reports, and I'm going to just give you a small sampling of these today.

We'll start with a new treatment option for patients with follicular lymphoma. Traditionally, this type of lymphoma, when it's symptomatic and needs therapy, the treatment of choice has been chemotherapy combined with a monoclonal antibody such as rituximab or obinutuzumab. But investigators, in a multicentered trial, decided to test whether you could use a chemotherapy-free treatment approach for patients like this by using rituximab combined with lenalidomide, which is also known as Revlimid, as a substitute for chemotherapy. And this is based on the fact that Revlimid plus rituximab has synergistic activity in patients with relapsed disease, so maybe we could see acceptable, high responses when it would be compared directly with rituximab plus chemotherapy.

So the way the trial worked is this. Patients who needed therapy, who had advanced-stage follicular lymphoma—they had never had any therapy before—were randomized to either the rituximab-lenalidomide combination or a rituximab-chemotherapy combination that could include the regimens CVP or cyclophosphamide, vincristine, prednisone, the same combination given with daunorubicin, or the CHOP regimen, or rituximab combined with bendamustine.

So over 1,000 patients were treated in this multinational study and the goal of the treatment, of the study was to prove that, actually, the ritux-lenalidomide was superior to the chemotherapy regimens. So the results showed, not superiority, but comparability. The complete remission rate between rituximab-len and ritux-chemotherapy were really identical, 48 and 53 percent, and the 3-year likelihood that the patients were progression-free, so had had no recurrence of their disease, was identical as well: 77 to 78 percent. There was no difference in survival which was 94% at 3 years in both arms.

The toxicities differed, however. There was more rash with the lenalidomide combination, whereas low blood counts and the need for growth factor support such as G-CSF was greater with chemotherapy. And it was also interesting that some of the traditional risk factors didn't seem to apply, as much, for lenalidomide. So what would be considered higher risk patients treated with chemotherapy, seemed to do somewhat better with the lenalidomide combination. The importance for a patient with untreated follicular lymphoma who needs therapy is that a chemotherapy-free approach with rituximab plus lenalidomide can be considered equivalent to rituximab-chemotherapy. It’s worth discussing this with your oncologist when you're considering what treatment to use initially.

The next subtype of lymphoma that I want to discuss is diffuse large B-cell lymphoma, and there's 2 presentations that I'm going to summarize. One, in patients with advanced stage disease, meaning stage III or IV. This identifies patients who have disease both above and below the diaphragm, to make it stage III, or stage IV means they've got bone marrow or other sites of involvement such as liver or bone. And the question being asked in this trial, which was part of the International GOYA trial, will take just a moment to explain. So the original GOYA trial compared whether a newer form of anti-CD20 monoclonal, namely obinutuzumab, which is also called Gazyva, how that would compare with the standard established monoclonal antibody, rituximab. And the initial findings of this study found that there was no benefit for the newer antibodies. So rituximab and CHOP chemotherapy was equivalent to obinutuzumab and CHOP chemotherapy in overall outcomes.

But there was an opportunity with this trial to answer a question that's been out there for many years, and that is how many cycles of treatment does one need? So the investigators took advantage of this large study which included 712 patients who were randomized to rituximab plus CHOP. Just over 500 of them received 6 cycles, and the remaining 186 received 8 cycles. Even the patients who got 6 cycles of CHOP chemotherapy also got an additional 2 doses of rituximab, so the immunotherapy monoclonal antibody was equivalent between the 2 arms. And the results of this showed that there was really no difference at all with a followup of about 3 years. Response rates were equivalent and there was no difference in the patients staying in remission. It didn't matter in terms of survival which was excellent in both arms. There was, however, more toxicity in patients who received 8 cycles, including cardiac problems, infections, etc.

These results showed that, I think we can finally put to rest the use of 8 cycles of rituximab-CHOP chemotherapy for advanced-stage large cell lymphoma. It's been an unknown entity because we never had a direct comparison of these. So we can now say that 6 cycles plus the additional 2 doses of rituximab is a standard for advanced-stage diffuse large B-cell lymphoma.

Now, what about patients who have limited-stage, so stage I or II diffuse large cell lymphoma? That means just a single lymph node area's involved or 2 adjacent lymph node areas. In the past, these were treated either with 6 cycles of rituximab-CHOP or sometimes cycles of R-CHOP plus local radiation therapy. And in this study, which took a long time to complete; it began in 2005, but it enrolled 592 patients who were then randomized to either 4 cycles or 6 cycles of treatment. Radiation therapy was not planned for any of these patients except for very specific locations of involvement such as testicular DLBCL where radiation therapy is a standard.

So the take-home message after over 5 years of follow-up for patients on this study showed that 4 versus 6 were identical. So 89% of patients were still in remission at 3 years after completing treatment, and the overall survival was really impressive, 98 to 99 percent in the 2 arms. So there was no benefit with limited-stage favorable disease. Now, who are these patients? So younger than age 60, stage I or II disease, and normal LDH. They did not have bulky disease, meaning there was no nodal mass more than 7 and a half centimeters. So if you fit those criteria, then you can benefit from a de-escalation of treatment and be spared the additional 2 cycles of R-CHOP.

Now, sticking with the topic of diffuse large B-cell lymphoma, a challenging problem in our field is for patients who relapse after their initial therapy, or in some cases, fail to respond to a treatment like rituximab-CHOP or an equivalent immuno-chemotherapy regimen. And a very exciting advance in the field, over the past few years, has been the development of chimeric antigen receptor T cells or CAR Ts. Traditionally, what we've done with patients who relapse or have resistant diffuse large cell lymphoma is to give them a second-line, high-dose chemotherapy regimen, and if they showed a good response to that, they could then go to a dose-intensive treatment with a follow-up consolidation by autologous stem cell transplantation. And with that, you can cure, overall, about 40% or so of patients. The CAR T-cell approach takes a very novel immunotherapy effort, and that is that a patient's own T-cells are removed from the peripheral blood, and then in the laboratory, they're modified and reprogrammed so they can attack the patient’s diffuse large B-cell lymphoma cells that are resistant to chemotherapy.

So there were 2 important follow-up studies, each of them involved 1 of the agents, the CAR T-cell products, that are approved by the Food and Drug Administration for patients with relapsed or refractory diffuse large cell lymphoma. The first used the CAR T known as axicabtagene ciloleucel. It's quite a complex name, but it goes by the abbreviation of axi-cel or the trade name is Yescarta. So in this study, the investigators wanted to show that this is a treatment that can be extended to many centers with the product, the CAR T being made in a central facility by the pharmaceutical company. So it was a retrospective study of 295 patients at 17 international centers: a lot of patients across a broad spectrum of sites in North America and Europe.

Virtually all the patients were able to develop and obtain a CAR T product. It included patients with some of the higher risk forms of the DLBCL such as double and triple-hit lymphoma. About 3% of patients died during the treatment, although only 1% of these were felt to be related to the treatment itself. The response rates were quite good, with about 80% of people responding. The complete remission rates at 30 days after the CAR T infusion were 47%. So it proved that you can use this centrally manufactured product. So the patients T-cells are collected at the local center, they're shipped to the manufacturing facility, the CAR Ts are generated, sent back to the home institution, and then infused. And I'll say a word in a moment, after I introduce the next paper, to explain some of the side effects of this treatment.

So the second study was also presented at the ASH meeting and published simultaneously in the New England Journal of Medicine in early December 2018. So this used the second FDA approved CAR T known as tisagenlecleucel or Kymriah. In this study, there were 93 patients who were able to receive a CAR T-cell infusion, 40% of them achieved a complete remission, and another 12% had a partial response. And that a year after their documented response, two-thirds of these patients were maintaining the response, including 79% of those who achieved a complete remission. So this trial again confirmed across multiple centers that CAR T-cells can be an effective therapy.

The side effects of both of these drugs can include something called cytokine release syndrome where the immunologic effects, essentially, release cytokines into the blood that can mediate a capillary leak, respiratory troubles, and low blood pressures, that can, in some cases, require intensive care unit support. This can be managed by other mediators that tamp down the cytokine effect such as an interleukin-6 antagonist.

The other toxicity which is less well understood and problematic can be neurologic effects which can include confusion, speech alterations and even coma. But again, approaches and treatments to identify and manage this are being developed. So CAR Ts have become established. They're available at a number of centers, but it's important to consider this as a treatment option in the setting of relapsed or refractory diffuse large cell lymphoma. The long-term curability is still unknown, although it's encouraging that patients with very resistant disease who'd get a good response can maintain that response out to a year and more. So we're going to be very interested to see how the longer-term follow-up comes together.

The final topic I wanted to mention today is Waldenstrom macroglobulinemia. So this is a unique form of indolent B-cell lymphoma where the lymphoma cells release a monoclonal immunoglobulin into the blood known as IGM. Now, IGM is a very large antibody, and because of that, when the levels are very high, patients can have problems with high viscosity or thickening of the blood, which can cause confusion, vision changes, sometimes respiratory problems. And these patients also can become anemic or develop enlarged lymph nodes or enlarged spleen. So one of the standard treatments for this disease is, again, the immunotherapy monoclonal antibody rituximab, but the responses are typically incomplete and somewhat short-lived. So it was exciting, a couple of years ago, when the targeted tyrosine kinase inhibitor, ibrutinib, which targets the bruton tyrosine kinase in malignant B-cells. This is an agent that's approved in chronic lymphocytic leukemia, and certain lymphomas such as mantle cell, marginal zone, as well as lymphoplasmacytic lymphoma or Waldenstrom macroglobulinemia.

So here's the study. Investigators had shown that if you combine rituximab with ibrutinib, that the response rates were improved as compared with rituximab by itself. And in a follow-up study that looked at this over a longer period of time, these benefits of the combined therapy were confirmed. These included patients without prior treatment or with prior treatment, with either chemotherapy or rituximab. And there was a confirmed benefit for the ibrutinib-rituximab combination in patients, whether they had had treatment before or not, and regardless of certain genetic markers that we use to assess risk in Waldenstrom. It was also shown that because these treatments continue indefinitely, as long as patients are responding and tolerating therapy, that the response rates improved over time. The side effects of treatment with ibrutinib are well-known, now, after several years of use across a variety of diseases, as mentioned, and include diarrhea, sometimes rash. You can see problems with easy bruising or bleeding, atrial fibrillation, and sometimes skin rash, or muscle and joint aches. But most patients are able to continue therapy and to benefit from it over an extended period of time.

So the combination of ibrutinib plus rituximab was shown to add benefit compared with rituximab alone, and again, is a treatment approach and option that you could consider whether you have previously untreated or relapsed Waldenstrom macroglobulinemia.

So overall, it was a very exciting meeting. We've had practice-changing data presented, and I've given you just a sampling of those. I think it's important for anyone dealing with lymphoma, or related malignancy, such as CLL or multiple myeloma to be very encouraged by the progress in the field, the opportunity to get much better responses with less toxicity and with minimal or no use of traditional chemotherapy. So we're pleased to be able to offer these treatment approaches for our patients. And I thank you for your taking part in the podcast and hope you found it useful. Thanks again.

ASCO: Thank you, Dr. Williams. Learn more about lymphoma 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.

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.

Jan 22 2019
18 mins
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