ASCO Education

Resources such as facilities, equipment, medications, and trained healthcare professionals are essential to provide proper care. Yet, many areas in the US and around the globe have challenges providing some of such resources. This ASCO Education podcast will explore oncology practice in low resource settings.  Dr. Thierry Alcindor, a medical oncologist at the Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston, Dr. Richard Ingram, a Medical Oncologist at Shenandoah Oncology in Winchester, Virginia, and Chair of the Appalachian Community Cancer Alliance and Dr. Sana Al Sukhun, an Adjunct Professor of Medical Oncology and Director of Oncology Practice at Al-Hayat Medical Center in Jordan will discuss the barriers they face providing cancer care in low resource areas in the US (1:48) and Jordan (11:52) and the one challenge that is key to solve in order for proper treatment to be administered in the US (29:07) and Jordan (31:42). Speaker Disclosures Dr. Sana A. Al-Sukhun: Honoraria – Novartis; Speakers' Bureau – Novartis, Roche, Pfizer; Travel, Accommodations, Expenses – Roche, BMS Dr. Richard Ingram:  None Dr. Thierry Alcindor: Consulting or Advisory – Merck, Bayer, BMS, Astra Zeneca, Astellas Scientific and Medical Affairs Inc.; Research Funding – Epizyme, EMD Serono, Karyopharm Therapeutics, Springworks, Astellas Pharma, Deciphera Resources  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed on the podcast page. Dr. Thierry Alcindor: Hello, dear ASCO audience, welcome to this episode of the ASCO Education podcast. Today, we will examine practicing oncology in a low-resource setting. Managing cancer patients is a multifaceted challenge. Resources such as facilities, equipment, medications, and trained healthcare professionals are essential to provide proper care. Yet, many areas in the US and around the globe have challenges providing some of such resources. I'm Dr. Thierry Alcindor. I'm a medical oncologist at the Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston. Joining us are Dr. Richard Ingram, a Medical Oncologist at Shenandoah Oncology in Winchester, Virginia, and Chair of the Appalachian Community Cancer Alliance. He is, as well, the current president of the Virginia State Oncology Society. We are also very pleased to be joined by Dr. Sana Al Sukhun. She is an Adjunct Professor of Medical Oncology and Director of Oncology Practice at Al-Hayat Medical Center in Jordan. She is also the past president of the Jordanian Oncology Society.  So, I'll begin with Dr. Ingram. You have experience with patients in the Appalachian region of the US by practicing medical oncology in rural northwestern Virginia for the past 25 years. Can you describe this unique region for our listeners and detail some of the challenges you face when providing care there? Dr. Richard Ingram: I have been practicing here in Northwestern Virginia for the past 25-ish years, and have seen over time barriers to care that I think could be applied anywhere. And, I think we'll hear some interesting stories today from our colleague from Jordan also, in that regard. The main barriers I think are somewhat slightly stereotypical but real where I am. There is a diverse population here, meaning a big geographic area and a somewhat underpopulated area. So, resources are scattered and scarce sometimes and located in concentrated areas. So, patients have difficulty with access to cancer screening, imaging, and sometimes downstream or tertiary care where I am. I have patients that will travel an hour and a half to two hours one way i.e., a three to four-hour round trip - sometimes over some difficult terrain, meaning some difficult roads out our way, both with mountains and some geographic challenges just to get to us. You can imagine the difficulty that is with either coordination of care with a multidisciplinary patient having to see multiple providers or more practically, a patient receiving radiotherapy on a daily basis. And, this not only is time but money because you're trying to make a decision about follow-up appointments and missing work at an hourly wage versus working that week and paying your bills. I have patients currently who are working around that. I have several concurrent chemo-radiotherapy patients - currently, actually two I saw this morning - in clinic, both of which live in a town called Petersburg, West Virginia, which is about an hour and 45 minutes one way. So, three and a half hours from us. And, we've had to connect them appropriately with resources around transportation to make sure they stay compliant with their care.  You have this empathy and drive to care for patients and try to apply the same care you would across the continuum. That socioeconomic status is not unique to Appalachia but I think is somewhat emblematic in our area - lovely, hardworking people and diligent in their craft. But, when you have barriers such as cancer diagnosis and now superimposed strain and stress on your family life and work life, it can throw things out of balance.  A similar patient of mine that I saw today actually in clinic, same area, same concurrent diagnosis, their big access issue is that they're also the primary caregiver for some grandchildren that are staying at home. They've taken in their grandchildren and, not unique to Appalachia, but somewhat in that we have a lot of multigenerational families living together. So, you're trying to help that person get through their therapy and still be the homemaker for grandchildren and try to battle their cancer diagnosis and at the same time not bankrupt them financially from a socioeconomic standpoint. Dr. Thierry Alcindor: What's the insurance coverage pattern like? Dr. Richard Ingram: In my area, about half to 60% of our patients are on either uninsured or they are on public insurance, whether that be Medicare or state Medicaid or exchange programs. From the private sector, there are private plans, but a lot of those are self-funded, meaning they are local municipalities, teachers' unions, first responders, and then a small pocket of what you and I would call traditional commercial insurance coverage. And so, for us, we for a lot of our patients have built relationships, for instance, we know this gastrointestinal group will take that insurance of a Medicaid or uninsured patient and this one won't, or vice versa. So, there is some fragmentation of care if you're not very conscious and deliberate at the medical oncology and radiation oncology side, which is in my practice about making sure the patient can get access to care. Dr. Thierry Alcindor: I understand. So you talked about the lack of adequate or complete primary care coverage. Do you have enough medical oncologists? Dr. Richard Ingram: Excellent question. I appreciate that. Yes. So we do, in that my group does and my region does. So we are very strong, as I like to say, the end of the funnel. You know, I consider cancer care screening a funnel you've got to screen through. I imagine you have a giant funnel of trying to screen through patients for the screening program appropriately and then the positive screens come out at the end of the funnel.  At the end of the funnel, we can receive these patients and take care of them and provide all of the touch points of surgical, radiation, medical oncology, genetic counseling, survivorship. My biggest passion and what I've tried to do in the Appalachian Community Cancer Alliance is raise awareness on the screening and getting the screening activities out into these rural communities so we can get stage migration to an earlier stage of cancer. Still take care of the people who develop positive screens and downstream disease, obviously, but it'd be nice to start getting stage migration to the left, meaning to earlier stages for patients.  What we really have out here is a lack of primary care doctors and stability of primary care doctors because it's a very difficult area to practice primary care with geography, very difficult area, with the payer mix and the socioeconomic status, and a difficult area for people to desire to live in when you're trying to practice primary care, not surrounded by every specialist. A rural primary care provider really has to be, in essence, a true solo practitioner in Appalachia. They have to have a broad skill set because they just don't have a cardiologist sitting next door or a neurosurgeon immediately available.  We have a full complement of surgical oncology specialists, radiation, three-dimensional stereotactic, clinical trials, genetic counseling, eight medical oncologists, a well-equipped ICU, and care. But our catchment area we serve is a geographic radius of two to two and a half hours, of which there's not much in between. There are some rural clinics, some community outposts, some critical access hospitals. And really creating that infrastructure of navigation has been the key success in our area of trying to navigate a patient through the system and trying to support these single clinics or smaller critical access hospitals from afar, support them intellectually with cognitive capabilities over the telephone to help work a consult up and trying to navigate the patient in.  But again, the physical or the geographic, or distance barriers are real, and the socioeconomic barriers are real. Even once we can make a link with the primary care doctor and be more than willing to see the patient, sometimes just physically getting them to us can be a challenge. Dr. Thierry Alcindor: So what is the Appalachian Community Cancer Alliance doing to improve cancer screening, cancer care outcomes in the region? Dr. Richard Ingram: Excellent question. So the Appalachian Community Cancer Alliance started organically. So myself, as president of Virginia, g

People who live in major cities in the US and abroad tend to benefit from better cancer care due to having access to more doctors, facilities and equipment. In contrast, those who live in rural areas face many challenges accessing consistent and quality care.  In Part Two of this ASCO Education Podcast Dr. Jack Hensold, a hematologist/oncologist in Bozeman, Montana and Chair of the ASCO Rural Cancer Care Task Force, Dr. Chris Prakash, Medical Oncologist in Paris, Texas and Medical Director of Texas Oncology and President of the Texas Society of Clinical Oncology, and Professor Sabe Sabesan, a Medical Oncologist in Townsville, Australia and the President-Elect of the Clinical Oncology Society of Australia will examine the realities of practicing oncology in rural areas.  They will discuss the need for rural populations to access clinical trials (1:42), using telemedicine for chemotherapy and clinical trials (3:00) and using political advocacy to improve cancer care in rural areas (13:00). Speaker Disclosures Sabe Sabesan: Speakers Bureau - Merck Sucharu Prakash: Speakers Bureau - Myriad Genetics   Jack Hensold:  Consulting or Advisory Role Company - Vibliome Therapeutics Resources Policy Recommendations for Improving Rural Cancer Services in the United States                                If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed on the podcast page.  Dr. Jack Hensold:  Hello and welcome to this two-part episode of the ASCO Education podcast. Today we will explore some real-time and real-world issues that oncologists face while practicing in rural areas in the US and abroad. I'm Dr. Jack Hensold, a Methodologist Oncologist in Bozeman, Montana, and chair of the ASCO Rural Cancer Care Task Force. I also serve as Medical Director of Regional Outreach at Bozeman Health. Joining me is Dr. Chris Prakash, an Oncologist and Medical Director of Texas Oncology and the President of the Texas Society of Clinical Oncology. Chris is also the Director of Quality Services for the statewide group and leads Texas Oncologist Precision Medicine Initiative.  Also joining me is Professor Sabe Sabesan, a Medical Oncologist in Regional, Australia. He's the President-elect of the Clinical Oncology Society of Australia and the Clinical Director of the Australian Teledyne Health Program, led by the Queensland State Department of Health. Professor Sabazin is an internationally recognized expert in the area of teleoncology and has developed and evaluated various oncology models to deliver cancer care closer to home.  In part one, our guests were explaining what got them into rural practice and the issues they face in patient transportation, telehealth, getting access to the latest information on treatments, and connecting with other colleagues to get insight on patient cases. Here, I ask Dr. Prakash about one issue that does not get talked about very often. Dr. Chris Prakash: I think we don't talk enough about access to clinical trials for rural populations. And that's a hard problem. These are regulated. But I wonder about real-world trials. Those are a little easier to do. Maybe we can put more patients on those, the hub-and-spoke model, that would be helpful in that. And I know people are trying and many societies are trying to enroll more rural populations in trials, but it continues to be a challenge. Dr. Jack Hensold: Correct. And actually, ASCO has a workforce right now that's trying to address this problem. That includes patient representatives, as well as, I think, people from National Cancer Institute and people from the pharmaceutical industry who've been on that task force and really is trying to address what are the barriers that keep us from getting trials out to our patients in rural areas because it is identified as a real problem. I think, as we all know, excellent cancer care requires access to clinical trials, and limited access means quality of care is going to be less.  Dr. Sabesan, you've been working on improving chemotherapy access in rural parts of Australia. Do you think your programs like tele-chemotherapy could be implemented in other regions and even in this country, the United States, and can they be applied to clinical trials and teletrials essentially? Dr. Sabe Sabesan: This is where I get really excited because the use of telemedicine, beyond providing consultations and then using it for chemotherapy and clinical trials, actually that's what keeps me up in the morning and keeps me awake at night as well. What I see these things as they are system solutions for a chronic problem. In tele-chemotherapy, it's simple, really. It's rural nurses. They are not chemotherapy nurses, they are general nurses. They administer selected chemotherapy regimens under the direct supervision of doctors, nurses, and pharmacies from larger centers through telemedicine, tele-nursing, and tele-pharmacy. So all we need for tele-chemotherapy to happen, if you have a larger center willing to supervise a smaller center or a larger center is now expected to do that through Health System directives, then I think we can implement that throughout the system.  And what we have done in Queensland, we got the Queensland State Government to implement that because we got a governance document called “Queensland Remote Chemotherapy Supervision Model and Guide for Implementation.” Basically, that articulates how to set up these services safely. But we already published that in the Journal of Oncology Practice in 2018, so that was a rewarding experience. But then what we found, we could do immunotherapy infusions, toxic chemotherapy like that and all those things in smaller centers, but we couldn't do clinical trials because, as Chris said, it's highly regulated. So then we said, “How come you can do toxic intensive chemotherapy but not clinical trials?” So that's how the Australasian teletrial model was born.  So we thought we will use the teletrial model to connect larger centers with smaller centers to create trial clusters so that you can really distribute the clinical trials activity to the regional, rural, and remote areas. So now we have an Australian teletrial model and a national teletrial principle as a government policy to enable that. Through some pilots we published in the Journal of Telemedicine & Telecare, the Australian government actually funded $125 million to transform the Australian clinical trial sector as a network and a national system, so that patients from regional, remote, and rural areas can access clinical trials, some or all aspects of clinical trials closer to home. So that is exciting because it's about one year into the program and already we could see the narrative is changing, and we are saying clinical trials need to be offered as networks, not as silos anymore, because of social justice and equity. So that's been becoming powerful.  And also, we've been now pushing the Ethics Committee to mandate that clinical trials need to be done as clusters because it is an ethical social justice issue. So I think if you have good governance and government support, I feel that we can actually implement these models in larger parts of the rural sector. Not all of them, but in larger parts. But I just wanted to highlight before I finish that the decentralized trials becoming popular and I feel like the decentralized trials are kind of hijacking the rural narrative here because they are not decentralized trials in my observation, they should be decentralized trial systems. And rather than bypassing hospitals and directly dealing with patients at home, in a lot of the trials, it seems that most of those patients are actually metropolitan patients. And I think any decentralized trial systems have to focus on partnerships with rural sectors, capability or capacity building of rural sectors so that you could really deliver clinical trials in a distributed network system to really fix this problem once and for all. Dr. Jack Hensold: Sabe, it sounds like there's much that we can learn from paying attention to what's going on in Australia. It seems like your group is well ahead of the curve in terms of what needs to happen in rural areas. Chris, comments about that as well? Dr. Chris Prakash: Yeah, I was going to say, I think excellent job, Sabe. Kudos to you for doing this in Australia. It's a clinical dilemma. It's an ethical dilemma. Sometimes clinical trials are fundamental to providing good quality care for our patients. But the American healthcare system is complex. Clinical trials, sad to say, I mean, that they're money makers for a lot of big institutions or pharmaceutical companies for sure. So what these companies are looking for is if they have a new drug, they want to get a trial done as quickly as possible, get positive data, and then get it approved. It's really hard to find a good phase III, randomized, placebo-controlled trial anymore. They're just nonexistent. They're all phase I, II, quick one year, get the data, and file for approval with the FDA. So I get your point. I think I would love to have a good trial where we can put patients on, rural patients on, but I don't know if that's going to be possible.  Now, what I'm doing in Texas Oncology, I'm the director of Quality Services, so that is my goal; is to give quality care to the whole state population wherever we can. And clinical trials is the most difficult task, I'm finding. I can make testing consistent, I can make treatment protocols consistent, but getting patients on clinical trials is a very difficult task. So, kudos to you, Sabe. You're doing an excellent job. Dr. Jack Hensold: It's actually the main enabler for us is actually the government intervention, because what we felt was the rural sector has been left in the hands of clinicians and local health managers for far

There was time during the early 70’s when the field of oncology began to take hold where the singular focus was to extend the patient’s life. In this ASCO Education podcast, our guest was one of the first to challenge that notion and rethink methods that focused the patient’s QUALITY of life. Dr. Patricia Ganz joins us to describe her transition from cardiology to oncology (6:00), the moment she went beyond treating the disease and began thinking about treating the WHOLE patient (10:06) and the joy of the increasing numbers of patients who survive cancer (21:47).  Speaker Disclosures Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Dr. Patricia Ganz: Leadership - Intrinsic LifeSciences  Stock and Other Ownership Interests - xenon pharma,  Intrinsic LifeSciences, Silarus Therapeutics, Disc Medicine, Teva,  Novartis, Merck. Johnson & Johnson, Pfizer, GlaxoSmithKline, Abbott Laboratories Consulting or Advisory Role - Global Blood Therapeutics, GSK, Ionis, akebia, Rockwell Medical Technologies, Disc Medicine, InformedDNA, Blue Note Therapeutics, Grail Patents, Royalties, Other Intellectual Property - related to iron metabolism and the anemia of chronic disease, Up-to-Date royalties for section editor on survivorship Resources If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT  Disclosures for this podcast are listed on the podcast page.   Pat Loehrer: Welcome to Oncology, Etc., an ASCO Education Podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University.  Dave Johnson: And I'm Dave Johnson, a Medical Oncologist at the University of Texas Southwestern in Dallas. If you're a regular listener to our podcast, welcome back. If you're new to Oncology, Etc., the purpose of the podcast is to introduce listeners to interesting and inspirational people and topics in and outside the world of oncology. Pat Loehrer: The field of oncology is relatively new. The first person treated with chemotherapy was in the 1940s. Medical oncology was just recognized as a specialty during the 1970s. And while cancer was considered by most people to be a death sentence, a steady growth of researchers sought to find cures. And they did for many cancers. But sometimes these treatments came at a cost. Our next guest challenged the notion that the singular focus of oncology is to extend the patient's duration of life. She asked whether an oncologist should also focus on addressing the patient's quality of life.  Dave Johnson: The doctor asking that question went to UCLA Medical School, initially planning to study cardiology. However, a chance encounter with a young, dynamic oncologist who had started a clinical cancer ward sparked her interest in the nascent field of oncology. She witnessed advances in cancer treatment that seemingly took it from that inevitable death sentence to a potentially curable disease. She also recognized early on that when it came to cancer, a doctor must take care of the whole patient and not just the disease.  From that point forward, our guest has had a storied career and an incredible impact on the world of cancer care. When initially offered a position at the West LA VA Medical Center, she saw it as an opportunity to advance the field of palliative care for patients with cancer. This proved to be one of her first opportunities to develop a program that incorporated a focus on quality of life into the management of cancer. Her work also focused on mental, dietary, physical, and emotional services to the long-term survivors of cancer.  That career path has led to many accomplishments and numerous accolades for our guest. She is a founding member of the National Coalition for Cancer Survivorship, served as the 2004 Co-chair of ASCO's Survivorship Task Force, and currently directs UCLA's Cancer Survivorship Center of Excellence, funded in part from a grant from Livestrong. Our guest is Dr. Patricia Ganz. Dr. Patricia Ganz: It's great to be with both of you today. Dave Johnson: We always like to ask our guests a little about their background, where they grew up, a little about their family. Dr. Patricia Ganz: Yes. I grew up in the city of Beverly Hills where my parents moved when I was about five years old because of the educational system. Unlike parts of the East Coast, we didn't have very many private schools in Los Angeles, and so public education was very good in California at that time. So I had a good launch and had a wonderful opportunity that many people didn't have at that time to grow up in a comfortable setting. Dave Johnson: Tell us about your mom. I understand she was a businesswoman, correct? Dr. Patricia Ganz: Yes, actually, my parents got married when my mom was 19 and my dad was 21. He was in medical school at the University of Michigan. His father and mother weren't too happy with him getting married before he could support a wife. But she worked in a family business in the wholesale produce business in Detroit. One of six children, she was very involved with her family in the business. And they were married, and then World War II started, my father was a physician in the military, so she worked in the family business during the war. After finally having children and growing up and being in Beverly Hills, she sat back and was a homemaker, but she was always a bit restless and was always looking for something to do. So wound up several years later, when I was in my early teens, starting a business with one of my uncles, an automobile parts business. They ultimately sold it out to a big company that bought it out.  Pat Loehrer: Where did your father serve in World War II? Dr. Patricia Ganz: He was actually D-Day Plus 21. He was in Wales during the war. They had to be stationed and moved down into the south before he was deployed. I have my parents’ correspondence and letters from the war. He liberated some of the camps. Actually, as I have learned about the trauma of cancer and post-traumatic stress that happens in so many people, our military veterans, most recently, I think he had post-traumatic stress. He didn't talk very much about it, but I think liberating the camps, being overseas during that time, as it was for that silent generation, was very profound in terms of their activities.   He wound up practicing medicine, and Los Angeles had a practice in industrial medicine, and it was a comfortable life. He would work early in the morning till maybe three or four in the afternoon and then go to the gym, there were moonlighting physicians who worked in the practice. But I kind of saw an easy kind of medicine, and he was always very encouraging and wanted me to go into medicine -- that I could be an ophthalmologist or a radiologist, good job for a woman. But I didn't really see the tough life of some of the internists and other people who were really working more 24/7, taking care of patients in the way medicine used to be practiced. Dave Johnson: Yeah. So you were interested in, early in your career, in cardiology. Could you tell us about that, and then a little bit more about the transition to oncology?  Dr. Patricia Ganz: I went away to college, I went to Harvard Radcliffe and I came home during the summers. And was interested in doing something during the summer so I actually in a pediatric cardiology research laboratory as a volunteer at UCLA for a couple of summers between my freshman and sophomore year then my sophomore and junior year. And then I actually got a California Heart Association Fellowship between my junior and senior year in college.  And this pediatric cardiology lab was very interesting. They were starting to give ketamine, it had an identification number, it wasn’t called ketamine. But they were giving it to children in the cardiac cath lab and then were very worried about whether it would interfere with measuring the pressures in the heart. So we had intact dogs that had catheters implanted in the heart, and the drug would be given to the animals and we would then measure their pressures in the heart.  That cardiology experience in 1970, the summer between my first and second year of medical school, the Swan-Ganz catheter was being tested. I worked at Cedars that summer and was watching them do the various studies to show the value of the catheter. And so by the time I was kind of finishing up medical school, I’d already invested all this time as an undergraduate. And then a little bit when I was in medical school and I kind of understood the physiology of the heart, very exciting. So that’s kind of where I was headed until we started my internship. And I don’t know if any of you remembered Marty Cline, but he was the oncologist who moved from UCSF to Los Angeles to start our hem-onc division. And very exciting, a wonderful bedside teacher.   And so all of a sudden, I’ve never been exposed to oncology and this was very interesting. But at the same time, I was rotating through the CCU, and in came two full-arrest patients, one of whom was a campus cop who was very obese, had arrested at his desk in the police station. And we didn’t have emergency vehicles to help people get on campus at that time. This was 1973 or 1974, something like that. And he came in full arrest, vegetable. And then another man had been going out of his apartment to walk his dog and go downstairs, and then all of a sudden his wife saw him out on the street being resuscitated by people. And he came in also in full arrest.   So those two experiences, having to deal with those patients, not being able to kind of comfort the families, to do anything about it. As well as taking care of patients in my old clinic who had very bad vascular disease. One man, extremely depressed with claudication and angina, all o

Providing high-quality cancer care to patients is the goal for any oncologist, yet there are many places across the globe that face multiple hurdles in achieving that goal. In this ASCO Education podcast we explore how one group is making a positive impact in the state of Surawak in Malaysia via the efforts of ASCO’s International Cancer Corp Program (ICC).  Dr. Roselle de Guzman, past chair of the Asia Pacific Regional Council of ASCO, Dr Voon Pei Jaye medical oncologist and onsite director of the ICC Program at Sarawak and Dr. Evangelia D. Razis medical oncologist focused on neuro-oncology from Athens, Greece and ASCO volunteer of the ICC Malaysia Program describe the benefits of implementing the efforts of Project ECHO (Extension of Community Healthcare Outcomes) (3:38), the challenges in providing quality cancer care in Sarawak (8:31) and details on how to volunteer for the ICC program (19:45).  Speaker Disclosures Dr. Roselle de Guzman:  Honoraria - Roche Oncology (Philippines); AstraZeneca; Merck Serono, MSD Oncology Recipient, Boehringer Ingelheim, Zuellig Pharma Consulting or Advisory Role - Roche Recipient, Novartis, Boehringer Ingelheim, AstraZeneca, Zuellig Pharma (ZP) Therapeutics, Eisai Recipient, MSD Oncology Research Funding - Centus Biotherapeutics Travel, Accommodations, Expenses - Hospira (Philippines), Roche (Philippines), Merck Sharp & Dohme, Eisai, Boehringer Ingelheim, AstraZeneca, Pfizer Dr. Evangelia D. Razis: Honoraria Company - Servier pharmaceuticals. ESMO Research Funding – Tesaro, IQvia, AstraZeneca, Exelixis, PPD Global, MSD Travel, Accommodations, Expenses - Genesis Pharmaceuticals, Roche, Pfizer, Karyo Dr. Pei Jye Voon: Research Funding - Novartis Recipient, Boehringer Ingelheim, Viracta Therapeutics Inc,  ROCHE, Merck KGaA, Merck Sharp & Dohme, BeiGene, AstraZeneca, Janssen-Cilag, Johnson & Johnson Resources  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed in the podcast page.  Dr. Roselle De Guzman: Providing high-quality cancer care to patients is the goal for any oncologist, yet there are many places across the globe that face multiple hurdles in achieving that goal. One such location has limited trained personnel, financial constraints, geographical challenges, and limited access to healthcare service in rural areas. The location, the state of Sarawak, located in the eastern part of Malaysia. The population is almost evenly split between urban and rural areas, which are the most dispersed in Malaysia.  The major challenge in Sarawak is the inadequate connectivity in the rural area and limited access to healthcare service. To address these issues, in 2020, a collaboration was formed between Sarawak General Hospital, University of Malaysia Sarawak and ASCO through ASCO's International Cancer Corp Program, or ICC for short. The ICC program is focused on three basic goals: incorporating a multidisciplinary approach into cancer care, integration of palliative care into oncology care, and quality improvement through ASCO's Quality Oncology Practice Initiative, or COPI program. This podcast will spotlight all the planning, activities, and results thus far of the ASCO ICC program in Malaysia. Hello, I'm Dr. Roselle de Guzman, past chair of the Asia Pacific Regional Council of ASCO. I am pleased to spotlight one of ASCO's collaborations with a lower-resource country to improve the quality of cancer care through a multifaceted approach. This year, we are focusing on Malaysia, where, through the ICC program, ASCO has been providing training in multidisciplinary care, palliative care, and quality measurement. Joining us later in the podcast will be medical oncologist Dr. Voon Pei Jye, who serves as the Onsite Coordinator for the ICC program at Sarawak.   First, we will speak to an ASCO volunteer of the ICC Malaysia Program, a medical oncologist focused on neuro-oncology, Dr. Evangelia Razis from Athens, Greece.  Welcome, Dr. Razis.  Dr. Evangelia Razis: Thank you. Thank you for the opportunity. Dr. Roselle De Guzman: First of all, Dr. Razis, what made you want to volunteer for the ICC Malaysia program, and what has been the most rewarding aspect of this service for you? Dr. Evangelia Razis: So, I've been actually collaborating with ICC for many years through ASCO and other programs as well, such as Honduras, and I find volunteering an extremely rewarding experience because you share and interact with colleagues from all over the world, you offer to those less fortunate, and you actually learn a lot through this process as well. So, volunteering is a very rewarding process for me, and I've been involved in it for many years. Plus, the opportunity to do something in neuro-oncology, which is very close to my heart, is very important, because this is a new field. I feel it needs to be exposed in all countries because it has many intricacies.  Dr. Roselle De Guzman: Well, that's really rewarding and must be really fulfilling work for you, Dr. Razis.   Dr. Razis, you also serve as a lead facilitator of the Project ECHO Neuro-Oncology Mock Tumor Board series, which delivers monthly online training to physicians from Malaysia. Can you tell us more about this project? What are mock tumor boards? Dr. Evangelia Razis: So, Project ECHO, the word stands for Extension of Community Healthcare Outcomes, and it's a project that has attempted to be near community healthcare delivered in low and middle-income countries through virtual media to support the healthcare in these areas. And in this particular effort, we are holding a neuro-oncology tumor board once a month since September with the Malaysia team. It's mock because we don't actually deliver specific patient advice for the purpose of patient care. We actually do it for educational purposes. So, we present cases and then discuss a topic.   The program has been set up for several months now by the Malaysia team based on their needs, which neuro-oncology topics they want to highlight. And we have a once a month, one-and-a-half-hour session, whereby cases are presented, and then an invited speaker from several places around the world, as I'll tell you in a minute, highlights this topic and then discusses the cases and discusses the questions that the group from Malaysia has.  And not only have we been able to be joined very regularly by the Sarawak team, but other parts of Malaysia have joined in, other centers in Malaysia have joined in different occasions. Now, the speakers have been experts from Europe and the United States based on their expertise in particular neuro-oncology topics.  Dr. Roselle De Guzman: So, Project ECHO is one of those innovative ways of delivering healthcare to extraordinarily challenging environments, those which are extremely remote or under-resourced areas. So to your knowledge, Dr. Razis, what improvements have been made since the implementation of Project ECHO? Dr. Evangelia Razis: Over the last nine months, I have noticed more insightful questions that show that some understanding of the standard neuro-oncology way of thinking, if you will, has come through to the colleagues that are joining us, though I must say that they were very knowledgeable from the beginning. I also hope that certain intricacies of neuro-oncology, such as, for example, the way to read scans and evaluate the fact that there may be pseudo progression or pseudoresponse, the way to integrate molecular parameters into the decision-making process, has now become part of the way they think about patients. And ultimately, the most important aspect has been the multidisciplinary approach to neuro-oncology and the constant use of all specialties to make a decision. Surgery, radiotherapy, radiology, pathology, all of these specialists need to come together to produce an appropriate decision for the patient. Dr. Roselle De Guzman: So one thing that's interesting as well is in 2013, Dr. Razis, your institution, HYGEIA Hospital in Athens, Greece, was one of the first outside the United States to join the Quality Oncology Practice Initiative or COPI program of ASCO. And your program was also the one to be accredited. So, Sarawak General Hospital in Malaysia is collaborating with ASCO as well for the COPI program that focuses on quality improvement. So, based on your experience, what benefits does the COPI program bring to an institution? Dr. Evangelia Razis: So, COPI, in fact, is an extremely useful way to streamline one's work and increase patient safety and patient satisfaction. I would also say that it helps reduce waste of resources, which is particularly important in resource-limited settings. And we do have a COPI version that is for limited resource settings. It's amazing, but just doing one's work lege artis does result not only in better outcomes but less waste. And that I think is extremely important for Sarawak. So, I think they will find it very useful to be streamlining their work through COPI. Dr. Roselle De Guzman: Thank you, Dr. Razis, for sharing your experience, your expertise, and your insights. Now, at this point, I would also like to introduce medical oncologist Dr. Pei Jye Voon, who serves as the Onsite Coordinator for the ICC program at Sarawak.  Dr. Voon, Welcome. Dr. Pei Jye Voon: Thank you so much.   Dr. Roselle De Guzman: Dr. Voon, can you describe what cancer care was like in this area of Malaysia for the past few years and what are the main challenges in providing quality cancer care? Dr. Pei Jye Voon: Yes, of course. So first of all, I would like to give a brief introduction of Sarawak, which is situated at the Borneo island of Malaysia and is the largest state in Malaysia with a very large land area populated by only 2.9 million people, meaning it is very sparsely populated. And for information, newly diagnosed cancer cases in our state is about 2300 c

Increasing diversity in the field of oncology is an ongoing task. Our next guest has made it her mission to increase those ranks as well as becoming the first African American woman to be a Brigadier General in the US Air Force. Dr. Edith Mitchell describes her early years growing up in rural Tennessee (2:52), the motivation for joining the Air Force in the 70’s (7:33) and strategizing to increase ethnic diversity in medicine and oncology (16:53). Speaker Disclosures Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Dr. Edith Mitchell: Leadership – Corvus; Honoraria - Sanofi, Exelixis; Consulting or Advisory Role Company - Genentech, Novartis, Merck, Bristol Myers Squib; Speakers' Bureau – Ipsen; Research Funding Company - Genentech, Sanofi  Resources (related podcasts, courses or articles) If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT  Disclosures for this podcast are listed on the podcast page.   Pat Loehrer:  Welcome to Oncology, Etc., an ASCO Education Podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University.  Dave Johnson: And I'm Dave Johnson, a Medical Oncologist at the University of Texas Southwestern in Dallas. If you're a regular listener to our podcast, welcome back. If you're new to Oncology, Etc., the purpose of the podcast is to introduce our listeners to interesting and inspirational people and topics in and outside the world of oncology. Pat Loehrer: Imagine knowing in your heart what you wanted to be in life. It usually takes people decades to figure that out, but our next guest knew at age three that she wanted to be a doctor and, later in high school, to be an oncologist. She's achieved much in her lifetime and has incorporated the "pay it forward" by mentoring many others. Dave Johnson: Our guest today is Dr. Edith Mitchell. I first met Edith over 40 years ago when we were both starting out our careers as junior faculty. She grew up in rural Tennessee, and as Pat mentioned, remarkably, she chose a career in oncology at a very early age in high school, despite the fact that oncology was barely a specialty at that time and the lack of role models, particularly role models of color, and women in particular. She received a Bachelor of Science degree in Biochemistry with distinction from Tennessee State University and a medical degree from the Medical College of Virginia and Richmond.   In 1973, while still attending medical school, Edith joined the Air Force, receiving a commission through the Health Profession Scholarship Program, and eventually rose to the rank of Brigadier General. She completed a residency in internal medicine at Meharry Medical College in Nashville and a fellowship at Medical Oncology at Georgetown University. Her research interests are broad and involve new drug evaluation, development of new therapeutic regimens, combined modality therapy strategies, patient selection criteria, and supportive care for patients with gastrointestinal malignancies.  She is the leader of the GI oncology program at Jefferson Medical College, Director of the Center to Eliminate Cancer Disparities, and Enterprise Vice President for Cancer Disparities at Jefferson's Sidney Kimmel Cancer Center. She's held a number of leadership positions, including those in ASCO, and she's a former president of the National Medical Association. I could go on forever. So, Edith, welcome, and thanks for joining us on Oncology, Etc.  Dr. Edith Mitchell: And thank you so much for the invitation, Dave and Pat, it is a pleasure.  Dave Johnson: You grew up on a farm, as I recall, in Tennessee. Perhaps you could tell us a little about your early life.  Dr. Edith Mitchell: I grew up on a farm that my great grandfather's mother received about 1863 when the Emancipation Proclamation was made. I was the fifth child in my family. My parents were working, my older siblings were in school, so my great-grandparents were my babysitters, so I spent a lot of time with them. He was 89 at the time, became ill, and I overheard family members and neighbors say that they couldn't take him to the hospital because Blacks were not treated properly in the hospital, so they were going to take care of him at home. A physician made a house call. When he left, I told my great-grandfather, “Pa, when I grow up, I'll be a doctor just like Dr. Logan and I'll make sure you get good health care.”  So, at three years, I decided I would become a doctor and I would make sure that Blacks received good health care. My work in disparity started when I was three. So, after my sophomore year in high school, there was a National Science Foundation program in Memphis at LeMoyne-Owen College. So, I applied and was accepted. And part of the time in Memphis that year, we were given opportunities to go to St. Jude. So my time at St. Jude made the decision that I would become an oncologist. I became really fascinated by cancers and in pathology, use of the microscope, and how cancers were all different, how they varied from the normal tissue for areas such as the colon or the stomach or the pancreas. Dave Johnson: It's amazing that that early in your life you made that kind of decision.  Can I back up just one moment? I want to ask you briefly about the doctor that visited your great-grandfather, Dr. Logan.  Dr. Edith Mitchell: Dr. Logan was a family physician, African American, and he had a great interest in Blacks being healthy. In fact, when the polio vaccine was made public, Blacks could only go one day per week because you couldn't go the times when whites were there. Dr. Logan obtained the vaccine and he would line the children up at his office. He gave me my first polio vaccine. He was a very handsome man. And, you know, Dave, I found out later that the medical school that he attended in Memphis was one of the ones closed as a result of the 1910 Flexner Report. So he had to go to Meharry in Nashville and take other courses to maintain his license to practice medicine.  Pat Loehrer: Were you the first one to go into medicine? Tell me about that background and how your family influenced you personally.  Dr. Edith Mitchell: Neither of my parents finished 8th grade, but they were very smart. They pushed their seven children to do well. They provided educational materials in our home and encouraged us to work and to take advantage of opportunities. Dave Johnson: Let's move forward a little bit. I thought I knew a lot about you, Edith, but I didn't realize that you were a Brigadier General. What was the motivation for joining the service in the ‘70s when you were at med school? Was it scholarship funding, or was there just patriotic zeal or a little of both? Dr. Edith Mitchell: My main objective was, for financial reasons - a scholarship covering all expenses of medical school, plus a monthly stipend. When I was in medical school, one of my laboratory instructors told me about this new scholarship program, and I said, "Okay, I just want to graduate from medical school." So he says, "Well, I know people in the surgeon general's office. I'll have them send you the information." He did, and I looked at it and didn't remember David, that my husband filled out the application. After my neurosciences final exam, I came home, and he says, "Your commission came in the mail today." So I said, "Okay." He says, "Well, I can swear you in. We can't do it at home because you have to have a witness. You take a nap, and then we're going out to job control, which was where all the aircraft controlled, the control room." We went there. We've got a picture of the swearing-in, and we then went to the officers club. It was Friday, and there were lots of people in his group from the Air Force Academy, from Citadel, Virginia Tech, and others. And they were all talking. "Yeah, Edith got a mail-order commission.”  So I owed the Air Force two years, and I practiced at Andrews Air Force Base, which was the presidential squadron. You hear the president always leaving Andrews Air Force Base. So I think I was 29 maybe, but I was young, and here I was taking care of senators and other important people in government, and these are people I'd only seen on TV before. So I had a really good experience. I received many accolades, but also many letters from people for whom I cared for. And I was therefore invited to stay on in the Air Force, either go to Walter Reed or to San Antonio. I said, "No, I'm going to Georgetown." So one of the VIPs, if I mentioned his name, you would know, said and wrote a letter for me that the Air Force should give me whatever I wanted and whatever I needed to continue in the Air Force. So I received my Air Force pay while I was a fellow at Georgetown.  So I stayed on. I got promoted early and engaged in Air Force work. I loved it, and I did well in that atmosphere and stayed on. After my second child was born, I decided I could not continue active duty and take care of two kids. So I left the Air Force, went to the University of Missouri, and someone called me one day and said, "You know, I hear you are at the University of Missouri now. Would you consider joining the National Guard?" I went, “ Joining the National Guard? Why would the National Guard want an oncologist?” And the information was, the Air National Guard wants good doctors, and you've got a great record. They invited me to St. Louis to just see the National Guard squadron there. I filled out the application while I was there and in a few days was appointed to the National Guard.  So after being there for a few years, I was discussing with one of the higher-ranking people in the National Guard who was in Washington, but visiting St. Louis. He said to me, "You know, you've done great work." He ha

In this episode of ASCO Educational podcasts, we'll explore how we interpret and integrate recently reported clinical research into practice. Part One involved a 72-year old man with high-risk, localized prostate cancer progressing to hormone-sensitive metastatic disease. Today’s scenario focuses on de novo metastatic prostate cancer. Our guests are Dr. Kriti Mittal (UMass Chan Medical School) and Dr. Jorge Garcia (Case Western Reserve University School of Medicine). Together they present the patient scenario (1:13), going beyond the one-size-fits-all approach (4:54), and thinking about the patient as a whole (13:39). Speaker Disclosures Dr. Kriti Mittal:  Honoraria – IntrinsiQ; Targeted Oncology; Medpage; Aptitude Health; Cardinal Health  Consulting or Advisory Role – Bayer; Aveo; Dendreon; Myovant; Fletcher; Curio Science; AVEO; Janssen; Dedham Group  Research Funding - Pfizer Dr. Jorge Garcia:  Honoraria - MJH Associates: Aptitude Health; Janssen Consulting or Advisor – Eisai; Targeted Oncology Research Funding – Merck; Pfizer; Orion Pharma GmbH; Janssen Oncology;  Genentech/Roche; Lilly  Other Relationship - FDA Resources  ASCO Article: Implementation of Germline Testing for Prostate Cancer: Philadelphia Prostate Cancer Consensus Conference 2019 ASCO Course: How Do I Integrate Metastasis-directed Therapy in Patients with Oligometastatic Prostate Cancer? (Free to Full and Allied ASCO Members) If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed on the podcast page.  Dr. Kriti Mittal: Hello and welcome to this episode of the ASCO Education Podcast. Today, we'll explore how we interpret and integrate recently reported clinical research into practice. In a previous episode, we explored the clinical scenario of localized prostate cancer progressing to metastatic hormone-sensitive disease. Today, our focus will be on de novo metastatic prostate cancer. My name is Kriti Mittal and I am the Medical Director of GU Oncology at the University of Massachusetts. I am delighted to co-host today's discussion with my colleague, Dr. Jorge Garcia.  Dr. Garcia is a Professor of Medicine and Urology at Case Western Reserve University School of Medicine. He is also the George and Edith Richmond Distinguished Scientist Chair and the current Chair of the Solid Tumor Oncology Division at University Hospitals Seidman Cancer Center.  Here are the details of the patient case we will be exploring: The patient also notes intermittent difficulty in emptying his bladder with poor stream for the last six months. A CT scan of the abdomen and pelvis demonstrates enlarged prostate gland with bladder distension, pathologically enlarged internal and external iliac lymph nodes, and multiple osteolytic lesions in the lumbar sacral, spine, and pelvic bones. A CT chest also reveals supraclavicular lymphadenopathy and sclerotic foci in three ribs. So this patient meets the criteria for high-volume disease and also has axial and appendicular lesions.  The patient was admitted for further evaluation. A bone scan confirmed uptake in multiple areas identified on the CT, and a PSA was found to be greater than 1500. Biopsy of a pelvic lymph node confirmed the diagnosis of prostate cancer. This patient is somewhat different from the first case we presented in terms of timing of presentation; this patient presents with de novo metastatic high-volume disease, in contrast to the first patient who then became metastatic after undergoing treatment for high-risk localized disease.  Would you consider these two cases different for the purposes of dosing docetaxel therapy when you offer upfront triplet therapy combinations?  Dr. Jorge Garcia: That's a great question. I actually do not. The natural history of someone with localized disease receiving local definitive therapy progressing over time is different than someone walking in with de novo metastatic disease. But now, with the challenges that we have seen with prostate cancer screening, maybe even COVID, to be honest with you, in North America, with the late care and access to testing, we do see quite a bit of patients actually walking in the office with de novo metastatic disease. So, to me, what defines the need for this patient to get chemotherapy is the volume of his disease, the symptoms of his disease – to be honest with you – and the fact that, number one, he is clinically impaired. He has symptomatic disease, and he does have a fair amount of disease, even though he may not have visceral metastasis. Then his diseases give him significant pain.  Oral agents are very good for pain control. I'm not disputing the fact that that is something that actually these agents can do. But I also believe I'm senior enough and old enough to remember that chemotherapy, when it works, can actually really alleviate pain quite drastically. So for me, I think that the way that I would probably counsel this patient is to say, "Listen, we can give you ADT plus an oral agent, but I really believe your symptomatic progression really talks about the importance of rapid control of your disease.” And based upon the charted data from the United States, and equally important, PEACE-1, which is the French version of ADT, followed by abiraterone, if you will, and certainly ARASENS is the standard of care for me for a patient like this will be triple therapy with ADT and docetaxel.  What I think is important for us to remember is that, in ARASENS, it was triple therapy together. I am worried sometimes about the fatigue that patients can have during the first six cycles of docetaxel. So oftentimes, I tell them if they're super fit, I may just do triple therapy up front, but if they I think they're going to struggle, what I tell them is, "Hey, we're going to put you on ADT chemotherapy. Right after you're about to complete chemo, we'll actually add on the darolutamide." So I do it in a sequence, and I think that's part of the data; we just still don't know if it should be given three at front or ADT chemo, followed by immediately, followed by an ARI. So I love to hear if that's how you practice or you perhaps have a different thought process. Dr. Kriti Mittal: So I usually start the process of prior authorization for darolutamide the day I meet them for the first time. I think getting access to giving docetaxel at the infusion center is usually much faster than the few weeks it takes for the prior authorization team to get copay assistance for darolutamide. So, in general, most of my patients start that darolutamide either with cycle two or, depending on their frailty, I do tend to start a few cycles in like you suggested. I've had a few patients that I've used the layered-in approach, completing six cycles of chemotherapy first and then layering in with darolutamide.  I think conceptually the role of intensifying treatment with an androgen receptor inhibitor is not just to get a response. We know ADT will get us a PSA response. I think the role of an androgen receptor inhibitor is to prevent the development of resistance. So, delaying the development of resistance will be pertinent to whether we started with cycle one, cycle six, or after. So, we really have to make decisions looking at the patient in front of us, looking at their ECOG performance status, their comorbidities, and frailty, and we cannot use a one-size-fits-all approach.  Dr. Jorge Garcia: Yeah, I like that and I concur with that. Thank you for that discussion. I think that you may recall some of our discussions in different venues. When I counsel patients, I tell the patients that really the goal of their care is on the concept of the three Ps, P as in Peter. The first P is we want to prolong your life. That's the hallmark of this regimen, the hallmark of the data that we have. That's the goal, the primary goal of these three indications is survival improvement. So we want to prolong your life so you don't die anytime soon from prostate cancer.  The second P, as in Peter, is to prevent, and the question is preventing what? We want to prevent your cancer from growing, from growing clinically, from growing radiographically, and from growing serologically, which is PSA and blood work. Now, you and I know and the audience probably realize that the natural history of prostate cancer is such that traditionally your PSA will rise first. There is a lead time bias between the rise and the scan changes and another gap in time between scans and symptoms. So it's often not the case when we see symptomatic disease preceding scans or PSAs, but sometimes in this case, it's at the same time. So that is the number one. And as you indicated, it’s prevention of resistance as well, which obviously we can delay rPFS, which is a composite endpoint of radiographic progression, symptomatic progression, and death of any cause.  But the third P is I called it the P and M, which is protecting and maintaining, and that is we want to protect your quality of life while we treat you. And we want to maintain your quality of life while we treat you. So to me, it's critically important that in addition of aiming for an efficacy endpoint, we don't lose sight of the importance of quality of life and the protection of that patient in front of us. Because, undoubtedly, where you get chemo or where you get an oral agent, anything that we offer our patients has the potential of causing harm. And I think it is a balance between that benefit and side effect profile that is so critically important for us to elucidate and review with the patient.  And as you know, with the charted data, Dr. Alicia Morgans now at Dana-Farber, published a very elegant paper in JCO looking at the impact of docetaxel-based chemotherapy as part of the charted data in the North American trial and into quality of life. And we clearly define that your quality of life

There are many treatments available for cancer  but how do you make csre delivery equitable? Given the various types of cancers how can you allocate the right resources to create equal outcomes? Dr. Lori Pierce has made equity a primary focus of her career. She describes how physics and radiology inspired her to be an engineer (6:06), and the moment she decided to transition from engineer to oncologist (12;54) and achieving the position of Vice-provost at the University of Michigan (23:01). Speaker Disclosures Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Dr. Lori Pierce:    Stock and Other Ownership Interests Company - PFS Genomics;  Patents, Royalties, Other Intellectual Property Company - UpToDate, PFS Genomics; Uncompensated Relationships - Bristol-Myers Squibb, Exact Sciences Resources  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. Disclosures for this podcast are listed in the podcast page.   Pat Loehrer: Welcome to Oncology, Etc. This is an ASCO Education Podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University.  Dave Johnson: Hi, I'm Dave Johnson at UT Southwestern in Dallas, Texas. I'm a Medical Oncologist. If you're a regular listener to our podcast, welcome back. If you're new to Oncology, Etc., the purpose of the program is to introduce listeners to interesting people and topics in and outside the world of oncology; hence the ‘et cetera’ in our name. Pat, we've got a great guest today. And we’ve got a great guest today. Pat Loehrer: Our next guest was able to do this despite living at a time when in the United States, certain groups of people faced tremendous barriers to achieve even the basic hint of equality. Our next guest is Lori Pierce. Dr. Pierce attended Duke University School of Medicine and completed a radiation oncology residency and chief residency at the Hospital of the University of Pennsylvania. She was then appointed as a senior investigator at the National Cancer Institute, the National Institutes of Health in Bethesda, Maryland, from 1990 to 1992. And in 1992, she joined the faculty at the University of Michigan, where she currently is a professor with tenure in Radiation Oncology.  Since coming to Michigan, she has served as Residency Director and Clinical Director in the Department of Radiation Oncology. In August of 2005, she was appointed by the University Board of Regents to be the Vice-Provost for Academic and Faculty Affairs, a position she still holds. In 2020, she was ASCO President, and while she ascended to the ASCO Presidency, that year COVID descended upon the Earth, and we may hear some stories about that. She's dedicated her career to the treatment of breast cancer patients. She's published over 200 manuscripts and book chapters and has received numerous teaching awards from the University of Michigan, multiple national organizations, and many national awards.  Dr. Pierce, thank you so much for joining us today.  Dr. Lori Pierce: I am so happy to join you both today. What an incredibly nice introduction. Thank you so much.  Pat Loehrer: You were born and raised in Washington, DC. And the family eventually moved to Philadelphia when I think you were in junior high school. Can you paint a picture of what schooling was like for you growing up? Dr. Lori Pierce: Well, schooling, education was just so important to my family and myself. And so, as you said, I was born and raised in DC. Moved to Philadelphia when I was just entering high school. And my parents, who are just the best people on the planet, didn't have an opportunity to go to college. At that point, a lot of people of color didn't really have that opportunity. So education was so important in my family. So if you think about the important issues in my life, there was our faith, our family, and education. And so my sister, who is four years older, she went to college first. After about two years, I transferred and actually graduated from the University of Pennsylvania, and I did that. It was my idea.  My parents at that point were living in Philadelphia. My mother was working at Penn, and so I would have free tuition if I went to Penn. And Penn is a great place as is Brown. My parents didn't ask me to transfer, but I did. And I received, obviously, an excellent education at both institutions. I majored in biomedical engineering and I minored in chemical engineering and was pre-med. I had to be strategic in how I was going to pay for my education because my parents and they took out loans, they covered everything, almost everything. My sister and I had some loans, but they took out most of the loans.  But they always had an agreement. And the agreement was that both my sister and I would have our college education covered by them. But anything in the graduate arena, we had to cover. So I had to be kind of strategic about that. So I actually applied to medical school and, as you know, got in, and deferred my admission so I could work and earn some money so I could pay for medical school. And I tell you, I did that specifically for the reason, for financial issues. But now this kind of thing is called a gap year. And in retrospect, it was the smartest thing I could have ever done because I took some time away, and during that time away, it made me even more motivated to apply my full attention to medicine.  And so education was very important. But I think sometimes you have to kind of step away to then regain the commitment that you need to move forward. And so by the time I started Duke, I was more than ready to be in medical school. Pat Loehrer: I know we talk about underrepresented minorities. I was a mechanical engineer at Purdue. And I can tell you, I don't think there was a single woman in engineering in most of my classes. There were just a few. So to be a woman in engineering is extraordinarily unique. So tell me a little bit about that decision-making and how you got into that. It may have been different in 10 or 15 years later, but were there a lot of women in engineering? Dr. Lori Pierce: No, not at all. And while there may have been two or three in biomedical engineering, there were hardly any in chemical engineering, and as you said, very few in mechanical engineering. So no. But I always was interested in physics. I liked those kinds of things, and hence I went into radiation oncology. It was a perfect blend of my studies and my interest. But no, I often was the only woman, or maybe one of two or three women in my classes, and I was certainly the only person of color in my classes. It taught you things though. It taught you to be comfortable being in that position and to know that you could do it just like anyone else could, and to know that probably a lot of eyes were on you to succeed. Some of that was self-imposed, but some of that was real. But I think learning those lessons then certainly came in handy when I went into medicine because while there are more women in medicine, especially now, compared to what it was when I came through, still, at that point, we were in the minority. And there were very few people of color in medical school where I went to. I was at Duke, and very few people there. You learned lessons early on, right?  Dave Johnson: Where did this interest in engineering originate? Dr. Lori Pierce: So it was really more of physics and radiology. So I, as a kid was a really thin kid, and I broke a couple of bones, and I ended up going to get X-rays. And I was fascinated by the X-rays. I was fascinated by this physics. I was fascinated by how you could push this button and these images would appear and I could see my broken bone. So that was really where it came from.  So I was pre-med. I did a lot of my pre-med work at Brown, and during the summers I was working in an industry. I was actually in Scott Paper Products industry outside of Philadelphia. And a couple of the other people there who I worked with closely were engineers. And I was just fascinated by it and seemed to be a good way of moving forward my own interest in the physics and the machinery and how it all worked. So I actually switched into engineering. So I switched from Brown to Penn. And being an engineer, it was a great way to make a good living for a year and a half. And I think as an engineer, and Pat, you can probably attest to this, you think in a certain way; you become very methodical in how you approach things. And while I'm sure there are a lot of other disciplines that will give you a similar type of approach, engineering really does—you're very objective in how you make decisions, and I think that serves well. And then, as I said, going into radiation oncology it was just a match made in heaven, so it all worked out great, I think. Pat Loehrer: I think I read that your sister was also into math, is that right?  Dr. Lori Pierce: My sister's a systems engineer with IBM. Incredibly gifted. Pat Loehrer: Yeah. Tell me about your parents. How did they guide you? What were your role models in terms of both you and your sister, in terms of math, physics, engineering? Dr. Lori Pierce: I already said my parents were incredibly hardworking and good people. They both had high school graduation education. My mother went straight through, but my father had to get an equivalency for his high school diploma because he was born and raised in North Carolina, had to work on the farm, and didn't get a chance to stay in school. But he got the equivalency of his high school degree.  It was interesting, my dad was just incredibly gifted for math. My father was just amazing in math. And my father and I always hung out. He was like my best friend and so I think my emphasis on math in part came from my dad. And I’ll say tha

People who live in major cities in the US and abroad tend to benefit from better cancer care due to having access to more doctors, facilities and equipment. In contrast, those who live in rural areas face many challenges accessing consistent and quality care.  In Part One of this ASCO Education Podcast Dr. Jack Hensold, a hematologist/oncologist in Bozeman, Montana and Chair of the ASCO Rural Cancer Care Task Force, Dr. Chris Prakash, Medical Oncologist in Paris, Texas and Medical Director of Texas Oncology and President of the Texas Society of Clinical Oncology, and Professor Sabe Sabesan, a Medical Oncologist in Townsville, Australia and the President-Elect of the Clinical Oncology Society of Australia will examine the realties practicing oncology in rural areas.  They discuss the difficulties of having to travel long distances for treatment (5:30), the effectiveness of telehealth (8:07) and solutions to recruiting a supportive care workforce in rural areas  and facilitating access to imaging facilities and specialized treatment (18:12). Speaker Disclosures Sabe Sabesan: Speakers Bureau - Merck Sucharu Prakash: Speakers Bureau - Myriad Genetics   Jack Hensold:  Consulting or Advisory Role Company - Vibliome Therapeutics Resources  Policy Recommendations for Improving Rural Cancer Services in the United States  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed on the podcast page.  Dr. Jack Hensold: Hello and welcome to this two-part episode of the ASCO Education Podcast. Today we will explore some real-time and real-world issues that oncologists face while practicing in rural areas in the US and abroad. Cities tend to benefit from having more doctors, facilities, and equipment to address the health needs of the population. In contrast, people who live in rural areas – estimated to be about 25% of the US population – face various challenges to obtaining consistent health care, including scarce medical personnel and infrastructure. Transportation of that care may involve considerable time and financial expense.  I'm Dr. Jack Hensold, the Hematologist/Oncologist in Bozeman, Montana, and Chair of the ASCO Rural Cancer Care Task Force. I also serve as Medical Director of Regional Outreach at Bozeman Health. Joining me is Chris Prakash, Oncologist and Medical Director of Texas Oncology and President of the Texas Society of Clinical Oncology. Chris is also the Director of Quality Services for the statewide group and leads Texas Oncologist's Precision Medicine Initiative.  Also joining me is Professor Sabe Sabesan, a Medical Oncologist in regional Australia. He is the President-Elect of the Clinical Oncology Society of Australia and Clinical Director of the Australian Teledyne Health Program, led by the Queensland State Department of Health. Professor Sabesan is an internationally recognized expert in the area of tele-oncology. He has developed and evaluated various oncology models to deliver cancer care closer to home.  Providing healthcare is a very involved career, more so in rural areas. Dr. Prakash, you finished your oncology training in Detroit, yet you practice primarily in rural Texas. Can you detail the factors that led to your decision in practicing oncology in a rural setting?  Dr. Chris Prakash: Thank you, Jack, for having me as part of this podcast. I finished my fellowship at Wayne State in Detroit, Michigan, and we were looking for a place to raise our kids and family and to find a good practice for myself. My daughter was two years old at that time. We were looking for a quiet, safe place with a laidback lifestyle, but at the same time a dynamic oncology practice. That's how I found East Texas, which is primarily a rural area. The small community here, good schools, and nice, accepting people really appealed to us. So we decided to give it a chance. We are still here almost 23 years later. My daughter has grown up and is in medical school. My son, who was born in Paris, Texas, is planning to go to med school next year.  Over the last couple of decades, I've found that practicing oncology in a rural setting is indeed very rewarding. You can make a difference in people's lives here. People are simple. They have faith and respect and follow doctors' advice. Practicing here, I've had a real chance to make a difference in not only people's lives but also in the overall healthcare system and in health policy. As you know, Jack, about 18% to 20% of the population lives in rural areas in the US. But only 3% of oncologists are available to provide care for them. So I'm not only fulfilling a need but also satisfying a desire to contribute.  Dr. Jack Hensold: Chris, could you clarify the nature of your practice? Are you a solo oncologist within a much larger group spread out over the state, or is there more than one oncologist on your site? Dr. Chris Prakash: Yeah, so I'm part of Texas Oncology, which is a statewide large group with multiple sites of service. In my location, there are three medical oncologists and one radiation oncologist. So we serve the catchment area of Northeast Texas and Southeast Oklahoma. But within Texas Oncology, we have locations spread out all over the state. Dr. Jack Hensold: Thank you for that clarity. Professor Sabesan, you started in Sri Lanka and are now in a rural area of Australia. How did that happen?  Professor Sabe Sabesan: I grew up in northern Sri Lanka in a village but moved to Australia because of the war in Sri Lanka in ‘90. So I did my med school in Adelaide, Australia. During my med school, we had to do a lot of rural clinical placements. And also as a result of that, I did my internship in a central Australian town called Alice Springs. Throughout that journey, I saw firsthand the difficulties these communities face in accessing healthcare, basic healthcare. So when I finished my training in medical oncology, I was looking for a place where I could contribute to minimizing these difficulties, but also taking an academic angle to this. So I chose a regional center called Townsville in North Queensland as our home that actually serves a large rural and indigenous population, but also it is an academic hub for rural medicine. So it kind of served my clinical and academic needs, and we've been there last 20 years now. Dr. Jack Hensold: A significant hurdle for patients in rural areas is transportation. Patients sometimes travel an entire day or stay overnight near the clinic, where they will be examined or treated. What resources have been developed to assist with transportation to help patients come back for test results, appointments, and treatments? Chris?  Dr. Chris Prakash: Transportation, that's a big hurdle for many patients across the country, but mainly for the rural population. So, as I just said, my practice is in Paris, Texas, but the draw is about a quarter of a million. So patients come to see us here to receive their medical care from all over Northeast Texas as well as Southeast Oklahoma, and there is no public transportation in many of these areas. The average time to commute for many of my patients is in excess of an hour and a half each way. Patients do travel sometimes an entire day. They sometimes have to stay overnight to receive their treatments the next day.  I recall a patient with tonsillar cancer last year who was receiving concurrent chemotherapy and radiation. So he lived almost three hours away. This was too cost prohibitive for him to travel back and forth on a daily basis for radiation therapy. So what he did was set up his camper right behind the cancer center, which certainly made it a lot easier for him to get his treatments that way. I would not recommend that as a routine practice for everybody, but it did work out for him   Close by there is a community of Choctaw Indians here in Southeast Oklahoma also, and they do have some options for transportation for just their citizens. And locally, some local church groups and volunteer organizations provide assistance with transportation for some patients as well. But that is a problem. Transportation is a big access issue for my population. Dr. Jack Hensold: Thank you. And just to make a comment, there's actually a fair amount of literature regarding what we refer to as financial toxicity associated with the need to travel. Sabe, do you have some transportation problems in your area? I would assume… Professor Sabe Sabesan: This is similar to what Chris and you are describing, Jack. Our area is 2000 by 1000 kilometers with about 650,000 population. There are scattered rural hospitals, but really there's no consistent public transport. But the government does pay for transport and accommodation. I heard that it doesn't fully cover it. But one of the disappointing things is that if you're traveling for clinical trials, that subsidy is not there for them. So that's probably one of the reasons why the governments have gone for the telehealth investment.   Dr. Jack Hensold: Thank you. Telehealth is a critical tool for providing healthcare in many areas, including rural areas. How do you manage the health literacy problems of ethnically, educationally, and socioeconomically diverse populations using telehealth? Chris? Dr. Chris Prakash: Telehealth has been around for a long time, but during the pandemic, that’s when we needed to keep our patients safe and away in their homes and still continue to give healthcare to them. So we conducted many visits through telemedicine at that time. Telehealth is especially used for many patients in rural areas because they have problems with access. But there are many challenges. As you know there is a broadband divide in the US. About 1 in 4 Americans do not have a good broadband connection so it is very difficult for them to perform a video telehealth visit. Audio works out okay a

Age is a main factor when determining cancer care. In this ASCO Education podcast we speak to one of the top leaders in treatment for older patients who has also credited mentorship as a foundation for his career. Dr. Hyman Muss describes his childhood in Brooklyn, serving as a general physician for troops in Vietnam (6:18), the doctor who influenced his choice of hematology and oncology (7:48) and creating one of the first geriatric oncology fellowships in the country (21:58).  Speaker Disclosures Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Dr. Hyman Muss: None More Podcasts with Oncology Leaders  Oncology, Etc. – Devising Medical Standards and Training Master Clinicians with Dr. John Glick Oncology, Etc. – Rediscovering the Joy in Medicine with Dr. Deborah Schrag (Part 1) Oncology, Etc. – In Conversation with Dr. Richard Pazdur (Part 1) If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Pat Loehrer: Welcome to Oncology, Etc., an ASCO Education Podcast. I'm Pat Loehrer, director of Global Oncology and Health Equity at Indiana University.  Dave Johnson: And I'm Dave Johnson of Medical Oncology at the University of Texas Southwestern in Dallas, Texas. If you're a regular listener to our podcast, welcome back. If you're new to Oncology, Etc., the purpose of our podcast is to introduce listeners to interesting and inspirational people and topics in and outside the world of Oncology. We have an inspirational guest today. Pat?  Pat Loehrer: If you ask anyone who's achieved any level of success and how they've achieved it, most likely they'll mention a number of people who've influenced them along the way. Quite often, these people reflect on their mentors, and after a certain time of accomplishment and reflection, they begin to mentor others. This is very much what our next guest has done. Dr. Hyman Muss has been a mentor to me and to Dave, and he's one of the most outstanding, wonderful people in the world, and we're so excited to have him today.   Dr. Hyman Muss served in the US Army in Vietnam, where he was awarded the Bronze Star Medal. He's an experienced Clinician Scientist, the Mary Jones Hudson Distinguished Professor of Geriatric Oncology at the University of North Carolina School of Medicine, and the Director of Geriatric Oncology Program at the UNC Lineberger Comprehensive Cancer Center Program. His interest in education and research is focused on cancer and older patients, and he is internationally recognized in this area. He's been the co-chair of the Alliance Committee on Cancer and Older Adults and won the BJ Kennedy Award from ASCO in Geriatric Care. His particular interest in research expertise is in the care of breast cancer patients, with a focus on the management of women who are of older ages. He's had a major interest in breast cancer survivorship and long-term toxicity of treatment and also served as the co-chair of the Breast Committee for the Alliance Group. He serves as a mentor for medical students, medical residents, junior faculty, and more recently, his Geriatric Oncology fellows. He served on the Board of Directors of the ASCO Foundation and on the ABIM, the American Board of Internal Medicine, where both Dave and I were privileged to work with him and witness his leadership and his deep breadth of knowledge.  Dr. Muss, thanks for joining us today. Dr. Hyman Muss: What a pleasure to be here. Thank you so much for inviting me. My mother would have loved the introduction.  Pat Loehrer: Well, speaking of that, tell us a little bit. You grew up in Brooklyn, so tell us a little bit about your parents. Your father was a dentist, I think, and your uncle was a general practitioner. So give us a little bit of the early life of Hy Muss. Dr. Hyman Muss: So I grew up in Brooklyn, New York. I was born and bred there. I went to Brooklyn Technical High School. I almost went to Brooklyn College, but I came back and went to Downstate Medical Center, which was just terrific. My tuition was $600 a year, but that's another story. My parents lived in the same neighborhood. My dad was a dentist, so we knew all the people. My uncle was the GP. You came into their office, sat down, and they saw you anytime, day or night, almost 24/7, something we're probably not going back to, but they had a profound influence on me. My uncle, as a GP, used to take me on house calls in Brooklyn when they were done, and he had an old Buick with MD plates. And I would go into these families, and they loved him, and they would give me ice cream and things. Maybe that's what made me a doctor. But it was a terrific and indelible experience. I had terrific parents. In those days, doctors and medical people usually lived in the same neighborhoods as their patients, so they really knew their people well. It was a terrific upbringing. I got to love medicine and have never had a look back. Dave Johnson: So your inspiration for a career in medicine obviously started at home. Tell us more about your formal education. You mentioned your high school education. What about college? And shortly thereafter?  Dr. Hyman Muss: Yeah, well, I went to Lafayette College. I was not the best high school student, but I had good college board scores or whatever they called them then. And I went to Lafayette and I thought I was going to be a chemist, a chemistry major. But I took enough premed courses and I spent a summer in a lab building cyclic ketones. And everybody was outside sitting on the lawn of the campus. And I was in there with all these distillation apparatus, and I said, “I don't think I can do this the rest of my life.” So I applied to medical school, and I got into several medical schools. But my father at that time was dying of metastatic bladder cancer. He had been a heavy smoker, and he was still working as a dentist. He worked until the day he unfortunately died. But I got into Downstate. We lived in Brooklyn, and my uncle, the GP, said, "Hy, you need to come home and help take care of your dad." I'm an only child, so I did. And I had a wonderful experience at Downstate.   Several years ago, I was listening to NPR and heard that one of my professors had won the Nobel Prize. Dr. Furchgott in physiology, one would have never thought. And I had a wonderful education and subsequently got into what was then Peter Bent Brigham in Boston, did my internship and residency there, joined the army and medical school, so I wasn't drafted, it was a program then. And then after first year of residency, I went to Vietnam, worked with an artillery battalion, a mystical experience, but no regrets. And then subsequently came back and did hematology and oncology at Brigham and at what was then the Jimmy Fund and Sidney Farber Cancer Center. And Tom Frei had just come. And I did hematology with a guy named Bill Moloney in Boston at Harvard. I'll tell you, a wonderful man. He was like a surrogate father. My dad had died by then, and I just feel I've had every opportunity to have a wonderful education and terrific mentors along the way. Dave Johnson: So we want to ask you about both of those gentlemen, but I would like to just, if I may, drop back to your experience in Vietnam. What was that like?  Dr. Hyman Muss: Well, I was 27 years old and I was put as the doctor for 500 men in artillery. My job was to take care of the general health of the troops. Fortunately, we didn't have many casualties. It wasn't a front war like my uncle, who was a GP actually in World War II, landed in Normandy about a week later and went all through World War II as a doctor. But Vietnam was an unusual war, there wasn't really a front. So my experience was I would go out to fire bases, which were units of about 100 men in the jungle, go out three days in a week in a helicopter, do sick call, check people. I dealt with really alcohol problems, unfortunately, a lot of drug problems. You had young people with really not a lot to do during the day, nothing much to do, and no real goal of being there. I did that for a while, and actually, the reason I got the Bronze Star was because I set up– It was nothing like standing in front of a machine gun. I'm not that kind of brave guy, but I set up a drug amnesty program so I got a lot of support from our regular field people to do this, so we didn't have to keep sending kids home with dishonorable discharges. And I learned a lot. I think we were reasonably successful. I learned a lot about artillery. I think overall it was a great experience in my life. Dave Johnson: Tell us how your interest in hematology and oncology originated. Where did that come from?  Dr. Hyman Muss: When I was an intern at the Brigham, Dr. Moloney was a very famous Harvard professor. He had studied war casualties after Hiroshima, he was one of the people that found the Philadelphia chromosome in CML. He was a guy that rounded on every single one of his leukemia patients every day. So I was an intern. So in those days I would go and see all the hematology people rounding because all the acute leukemia patients and all the serious cancer patients were right on the floors, right on the wards. We had 17-bed wards, and then we had some private rooms. And he loved what he did. And before I left for Vietnam, we didn't have Ara C and daunomycin. So every leukemia patient I saw died. This is '68 to '70. Yet we tried all these different regimens. Occasionally you got someone who did well for six months, a year. But his bedside manner was absolutely wonderful to me. He knew all the patients. He'd ask them about where they lived in Boston. His humanism was terrific, and yet I loved the diseases he treated. The stakes were high. We didn't have good treatment, and I decided that that's prob

To stay up to date with new treatments and standards of care medical oncologists in the United States are required to take the ABIM Maintenance of Certification exam, a ten-hour test, every ten years. This ASCO education podcast focuses on the Longitudinal Knowledge Assessment. An alternative test that offers more flexibility in medical certification.     Our guests are Dr. Suresh Nair Physician-in-Chief of Lehigh Valley Cancer Institute in Allentown, Pennsylvania and Chair of the ABIM Medical Oncology Board and Dr. Olatoyosi Odenike, Associate Professor of Medicine at the University of Chicago and member of the ABIM Medical Oncology Board.   Speaker Disclosures  Dr. Suresh Nair:   Research Funding - Bristol-Myers Squibb Recipient; Merck; Nektar Therapeutics; Mirati Therapeutics; Strata Oncology   Dr. Olatoyosi Odenike:   Consulting / Advisory Role – Abbvie; Impact Biomedicines; Celgene Recipient; Novartis; BMS; Taiho; CTI Biopharma; Threadwell therapeutics; Blueprint Medicines; SERVIER; Kymera; Bristol-Myers Squibb/Celgene  Research Funding - Celgene; Incyte; Astex Pharmaceuticals; NS Pharma; Abbvie; Janssen Oncology; Oncothyrapy; Agios; AstraZeneca; CTI BioPharma Corp Recipient; Kartos; Aprea AB; Bristol-Myers Squibb; Daiichi Sankyo; Loxo; Novartis  Resources  To find out more about the ABIM LKA, go to https://www.abim.org/lka/  For a video walk-through, visit https://www.youtube.com/watch?v=C0-qaUQmQXc  Sign in to the ABIM Physician Portal to sign up for LKA by June 30, 2023: https://portal.abim.org/   To find out more about how ASCO supports physicians engaged in ABIM MOC, go to https://old-prod.asco.org/meetings-education/continuing-education-moc  If you are interested in joining the ABIM Item Writing Task Force for Medical Oncology, find out more and submit your application at: https://www.abim.org/about/boards-and-committees/openings/medonc-iwtf-physician/  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed in the podcast page.  Dr. Suresh Nair: The medical profession is one where new treatments and standards of care are being discovered and applied frequently, especially in oncology. Staying up to date with such practices allows the physician to provide the highest quality of care. How is this accomplished? By taking part in the Maintenance of Certification, or MOC. The traditional MOC assessment takes about 10 hours to complete and gives you ten years to be reported as certified before your next assessment is due. But given today's world where new treatments and standards of care are advancing rapidly, a more continuous assessment approach is warranted to help oncologists stay up to date.  This ASCO Education Podcast explores a new alternative to the every decade MOC exam for medical oncology. It's known as the Longitudinal Knowledge Assessment or LKA. I'm Suresh Nair MD, the Physician Chief of the Lehigh Valley Topper Cancer Institute in Allentown, Pennsylvania, and Chair of the American Board of Internal Medicine Medical Oncology Board. I will guide you through a general overview of the LKA, what it is, how it works, what the advantages are, and top-level need-to-know information. Joining me is my medical oncologist colleague, Dr. Olatoyosi Odenike, who's a professor of medicine and director of the Leukemia Program at the University of Chicago and serves as a fellow member of the ABIM Medical Oncology Board.  To begin, here are the essential differences between the ten-year maintenance of certification exam or MOC exam and the Longitudinal Knowledge Assessment, the LKA. Both are being used to help medical professionals maintain a working knowledge of the latest treatments and standards in use in their field. The MOC is administered every ten years at specified locations, lasts about 10 hours, and the results are available after two months. The LKA is another option. It has a five-year cycle during which you answer questions on an ongoing basis and receive regular feedback on how you're performing. Dr. Odenike has taken the LKA and the MOC.  Toyosi, please describe the preparation and the actual experience of taking the traditional MOC test. How much time did you take to prepare for the exam and how did you fit that prep time into your busy schedule? Dr. Olatoyosi Odenike: Thank you so much, Dr. Nair. For the traditional MOC, I started preparing about six months ahead of time and it was challenging to find time to prep and to fit that into an already busy schedule. It came down to blocking out any available time, particularly on the weekends, in the few weeks leading up to the actual examination date. It was also challenging to find time to dedicate a whole day to taking the exam and traveling down to the test site to do so. Dr. Suresh Nair: Today, the LKA is another option for busy oncologists. In 2022, the American Board of Internal Medicine launched the LKA after years of working with and listening to the physician community to understand their needs. As long as you're meeting the LKA participation requirement and other MOC requirements you'll continue to be publicly reported as certified for your entire five-year LKA cycle. The LKA is designed to provide greater flexibility, more convenience, and more immediate feedback, helping physicians stay current. Dr. Odenike, what has been your experience so far with the LKA? Dr. Olatoyosi Odenike: So far, I have found the process far easier to navigate than the MOC. Registering for the LKA on the ABIM physician portal was very easy. There are 30 questions per quarter, and I chose to get weekly reminders of the due date, along with a link to access the portal and the LKA questions. I find this to be so convenient, I can determine when to access and complete the questions, which I have often done on block closer to the due date. You are able to do this and fit this in your schedule any way you choose, which is a big improvement on the traditional MOC. Dr. Suresh Nair: Is the LKA a big time commitment for you? 30 questions per quarter seems like a lot. How does it compare to the traditional ten-year model?  Dr. Olatoyosi Odenike: There's a four-minute time limit per question. So technically, you can answer all 30 questions in one afternoon. Some physicians report doing this in two hours. Data gathered over the last year have shown that most participants answer questions in under two minutes. And how they approach it is unique to each person. Some set aside a little time each week to answer questions until they're finished. Others, like me, will do it all at once or over the course of one week near the end of the quarter. You could do one a day with your morning coffee if you wanted to. We have found the structure to be significantly more flexible than the traditional MOC.  We have a question for you, Dr. Nair. Can physicians sign up for the LKA now, even if they're not due for an assessment? Dr. Suresh Nair: You can only sign up in the year that you're due, or rather, starting in the December prior to your due year. So, physicians due for an assessment in 2023 were able to enroll starting December 1, 2022. Physicians who are recently certified or who are not due for a few more years have to wait until their due year to sign up for the LKA. Dr. Olatoyosi Odenike: What is the last date to sign up for the LKA? Dr. Suresh Nair: The last day to enroll in 2023 is June 30. If you missed the enrollment date for the LKA this year, you can still opt to take the MOC exam in the fall without letting your certification lapse. MOC registration closes August 15.   Dr. Olatoyosi Odenike: What happens if you don't pass after five years? Dr. Suresh Nair: If you don't pass after five years, you enter the grace period as long as you're meeting your other MOC requirements and will continue to be reported as certified during that time. You'll have one calendar year to pass the traditional MOC exam. In some ways, this is somewhat risk-free going with the LKA in that regard. Can physicians still take the MOC exam if they prefer to? Dr. Olatoyosi Odenike: The MOC exam is still available in spring and fall each year for most certificates, including med ONC and hematology, the LKA is just another option. Many physicians prefer to take the traditional exam or if they're certified in multiple specialties, they use both the exam and the LKA to balance their time and areas of expertise better. Some physicians take the LKA in hematology and/or medical oncology while using the exam to remain certified in internal medicine, for instance, or vice versa.  I have a question for you, Dr. Nair. Who is eligible to take the LKA? How can physicians know if they're eligible? Dr. Suresh Nair: LKA is offered in 15 specialty areas. All board-certified physicians in their assessment due year, except those in a grace period, are eligible. All physicians certified before 1990, all physicians with a lapsed certification. In fact, I had trained in both hematology and oncology 30 years ago, and I practiced medical oncology at two academic community hospital systems. I actually signed up for the LKA this past year to regain certification in hematology that had lapsed after my first 10 years, and I've had a great experience. I have finished a year of taking the test. I've gotten assessments. I see what my strong points and weak points are. I've actually ordered the ASH_SAP and I'm reading up on my weak points and I'm continuing this process. It really starts growing on you.  I'd like to thank Dr. Odenike for sharing your real-time experience in taking both the MOC and the LKA. I would like to extend an opportunity for all listeners interested in keeping their certifications through the LKA by going to the ABIM Physician portal www.abim.org. That's www.abim.org or go to the notes on the podcast page to access the link, as well as other resour

In this episode of ASCO Educational podcasts, we'll explore how we interpret and integrate recently reported clinical research into practice. The first scenario involves a 72-year old man with high-risk, localized prostate cancer progressing to hormone-sensitive metastatic disease.  Our guests are Dr. Kriti Mittal (UMass Chan Medical School) and Dr. Jorge Garcia (Case Western Reserve University School of Medicine). Together they present the patient scenario (1:12), review research evidence regarding systemic and radiation therapy for high-risk localized disease (5:45), and reflect on the importance of genetic testing and (10:57) and considerations for treatment approaches at progression to metastatic disease (16:13).  Speaker Disclosures Dr. Kriti Mittal:  Honoraria – IntrinsiQ; Targeted Oncology; Medpage; Aptitude Health; Cardinal Health  Consulting or Advisory Role – Bayer; Aveo; Dendreon; Myovant; Fletcher; Curio Science; AVEO; Janssen; Dedham Group  Research Funding - Pfizer Dr. Jorge Garcia:  Honoraria - MJH Associates: Aptitude Health; Janssen Consulting or Advisor – Eisai; Targeted Oncology Research Funding – Merck; Pfizer; Orion Pharma GmbH; Janssen Oncology;  Genentech/Roche; Lilly  Other Relationship - FDA Resources  ASCO Article: Implementation of Germline Testing for Prostate Cancer: Philadelphia Prostate Cancer Consensus Conference 2019 ASCO Course: How Do I Integrate Metastasis-directed Therapy in Patients with Oligometastatic Prostate Cancer? (Free to Full and Allied ASCO Members) If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Dr. Kriti Mittal: Hello and welcome to this episode of the ASCO Education Podcast. Today we'll explore how we interpret and integrate recently reported clinical research into practice, focusing on two clinical scenarios: localized prostate cancer progressing to hormone-sensitive metastatic disease; and a case of de novo metastatic hormone-sensitive prostate cancer progressing to castration-resistant disease.   My name is Kriti Mittal and I am the Medical Director of GU Oncology at the University of Massachusetts. I am delighted to co-host today's discussion with my colleague, Dr. Jorge Garcia. Dr. Garcia is a Professor of Medicine and Urology at Case Western Reserve University School of Medicine. He is also the George and Edith Richmond Distinguished Scientist chair and the current chair of the Solid Tumor Oncology Division at University Hospital's Seidman Cancer Center. Let me begin by presenting the first patient scenario.  Case 1: A 72-year-old male was referred to urology for evaluation of hematuria. A rectal exam revealed an enlarged prostate without any nodules. A CT urogram was performed that revealed an enlarged prostate with bladder trabeculations. A cystoscopy revealed no stones or tumors in the bladder, but the prostatic urethra appeared to be abnormal looking. Transurethral resection of the prostate was performed. The pathology revealed Gleason score 4+5=9 prostate cancer, involving 90% of the submitted tissue. PSA was performed one week later and was elevated at 50. Patient declined the option of radical prostatectomy and was referred to radiation and medical oncology.   So I guess the question at this point is, Dr. Garcia, in 2023, how do you stage patients with high-risk localized prostate cancer and how would you approach this case? Dr. Jorge Garcia: That's a great question and a great case, by the way, sort of what you and I in our practice will call ‘bread and butter’. Patients like this type of case that you just presented come from different places to our practice.  So either they come through urology or oftentimes they may come through radiation oncology. And certainly, it depends where you practice in the United States, at ‘X’, US, they may come through medical oncology.   So I think that the first question that I have is in whatever role I'm playing in this case, where the patient has seen a urologist or a rad onc or me first, I think it's important for us in medical oncology, at least in the prostate cancer space, to talk about how do we think of their case and put those comments into context for the patient. It's very simple for you to tell a patient you can probably have surgery, radiation therapy, but at the end of the day, how do you counsel that patient as to the implications of the features of his disease is going to be really important. I use very simple examples that I relate to my patients, but really this patient is a patient that has very high-risk prostate cancer based upon the NCCN guidelines and how we actually stratify patients into what we call low-risk, intermediate-, and high-risk, and between those very low and very high risk.  So his PSA is high, very high, I would argue. His Gleason score, now, what we call group grading is high. He has high-volume disease. So the first question that I would have is, what are the choices for treatment for a patient like this? But even before you and I may talk about treatment options, we really want to understand the volume of their disease and whether or not they have localized prostate cancer with high-risk features or whether or not they have locally advanced or hopefully not metastatic disease. So back in the days prior to the FDA approval for PSMA PET imaging, we probably will have a Technetium-99 whole-body bone scan, and/or we probably will actually use CT scanning. Most people in the past, we used to do just a CT of the abdomen and pelvic region. As you know, with the movement of oral agents in the advanced setting, I think most of us will do a chest CT, abdomen and pelvic region, and certainly we also probably will have a Technetium-99 bone scan.  Now, with the utility and the use of PET imaging, I think most people like him will probably undergo PET PSMA, where you use F-18 PSMA or Gallium-68 PSMA. I think the importance depends on how you look at the approval of these two technologies. I think that PET PSMA imaging is here to stay. It's probably what most of us will use. And based upon that, we will define yet the truest stage of this patient. So right now, what we know is he has high-risk features. Hopefully, their disease is localized. We'll probably put the patient through an imaging technology. If you don't have access to a PET, then obviously CT and a bone scan will do. But if you do, the PET will actually help us define if the patient has disease outside of the prostate region, in the pelvic area, or even if they have distant metastases. Dr. Kriti Mittal: I would agree with that approach, Dr. Garcia. I think in the United States, we've been late adopters of PSMA scans. I think this patient with high-risk localized disease, if insurance allows at our institution, would get a PSMA for staging. There are still some patients where insurance companies, despite peer-to-peer evaluations, are not approving PSMAs. And in those situations, the patient would benefit from conventional CTs and a bone scan. So let's say this patient had a PSMA and was found not to have any regional or distant metastases. He decided against surgery, and he is seeing you as his medical oncologist together with radiation. What would your recommendations be?  Dr. Jorge Garcia: I think the bigger question is, do we have any data to suggest or to demonstrate that if in the absence of metastatic disease with conventional imaging or with emerging technologies such as PSMA PET, there is no evidence of distant disease, which I think you probably agree with me, that would be sort of unlikely with a patient with these features not to have some form of PSMA uptake somewhere in their body. But let's assume that indeed then the PSMA PET was negative, so we're really talking about high-risk localized prostate cancer. So I don't think we can tell a patient that radical prostatectomy would not be a standard of care. We never had a randomized trial comparing surgery against radiation therapy. This patient has already made that decision and surgery is not an option for him. If he, indeed, had elected radiotherapy, the three bigger questions that I ask myself are where are you going to aim the beam of that radiation therapy? What technology, dose, and fractionation are you going to use? And lastly, what sort of systemic therapy do you need, if any, for that matter? Where we do have some data maybe less controversial today in 2023 compared to the past? But I think the question is, do we do radiation to the prostate only or do we expand the field of that radiation to include the pelvic nodes?  Secondly, do we use IMRT? Do you use proton beam or not? Again, that's a big question that I think that opens up significant discussions. But more important, in my opinion, is the term of hypofractionation. I think the field of radiation oncology has shifted away from the old standard, five, seven weeks of radiation therapy to more hypofractionation, which in simple terms means a higher dose over a short period of time. And there was a concern in the past that when you give more radiation on a short period of time, toxicities or side effects would increase. And I think that there is plenty of data right now, very elegant data, demonstrated that hypofractionation is not worse with regards to side effects. I think most of us will be doing or supporting hypofractionation. And perhaps even to stretch that, the question now is of SBRT. Can we offer SBRT to a selected group of patients with high-risk prostate cancer? And again, those are discussions that we will naturally, I assume, in your practice, in your group, you probably also have along with radiation oncology.  Now, the bigger question, which in my mind is really not debatable today in the United States, is the need for systemic therapy. And I think we all will go back to the old data from the European EORTC data looking at the duration of androgen deprivatio

The early 1970’s saw the start of the medical specialty we now know as oncology. How does one create standards and practices for patient care during that time? Dr. John Glick is a pioneer during the dawn of oncology. He says that early work involved humanity, optimism, and compassion, all of which were the foundation of his career. Dr Glick describes the clinical experiences that drove him to oncology (4:28), his rapport with patients, which was portrayed in Stewart Alsop’s book Stay of Execution (9:21), and his groundbreaking work developing the medical oncology program at the University of Pennsylvania (12:22). Speaker Disclosures Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Dr. John Glick: None More Podcasts with Oncology Leaders    Oncology, Etc. – In Conversation with Dr. Richard Pazdur (Part 1) Oncology, Etc. – HPV Vaccine Pioneer Dr. Douglas Lowy (Part 1) Oncology, Etc. – Rediscovering the Joy in Medicine with Dr. Deborah Schrag (Part 1)  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org.   TRANSCRIPT Disclosures for this podcast are listed in the podcast page. Pat Loehrer: Welcome to Oncology, Etc. This is an ASCO education podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University. Dave Johnson: And I'm Dave Johnson, a medical oncologist at the University of Texas Southwestern in Dallas, Texas. If you're a regular listener to our podcast, welcome back. If you're new to Oncology, Etc., the purpose of our podcast is to introduce listeners to interesting people and topics in and outside the world of oncology. Today's guest is someone well-known to the oncology community. Dr. John Glick is undoubtedly one of oncology's most highly respected clinicians, researchers, and mentors. I've always viewed John as the quintessential role model. I will add that for me, he proved to be a role model even before I met him, which hopefully we'll talk about a little bit later.   To attempt to summarize John's career in a paragraph or two is really impossible. Suffice it to say, he is to the University of Pennsylvania Cancer Center what water is to Niagara Falls. You can't have one without the other. After completing his fellowship at NCI in Stanford, John joined the Penn faculty in 1974 as the Ann B. Young Assistant Professor. Some five decades later, he retired as the director of one of the most highly respected comprehensive cancer centers in the nation. Among his many notable accomplishments, I will comment on just a few. He established the Medical Oncology program at Penn and subsequently directed the Abramson Cancer Center from 1985 to 2006. Interestingly, he established the Penn Medicine Academy of Master Clinicians to promote clinical excellence in all subspecialties across the health system. He's been a driving force in philanthropy at Penn Medicine, culminating in his role as Vice President Associate Dean for Resource Development.  Over the past several decades, he has helped raise over half a billion dollars for Penn Med. We need you on our team, John. As a clinician scholar, John's research has helped shape standards of care for both breast cancer and lymphomas. For example, he pioneered the integration of adjuvant chemotherapy and definitive breast irradiation for early-stage breast cancer. In 1985, he chaired the pivotal NCI Consensus Conference on adjuvant chemotherapy for breast cancer. He also was a driving force in a clinical landmark study published in The New England Journal some 20 or so years ago about the role of bone marrow transplant for advanced breast cancer. Most impressive of all, in my opinion, is John's legacy as a mentor to multiple generations of medical students, residents, and fellows.   So, John, we want to thank you for joining us and welcome. Thought we might start by having you tell us a little about your early life, your family, your parents, where you grew up, and how you got into medicine. Dr. John Glick: Well, thank you for having me on the podcast, Pat and David, it's always a pleasure to be with you and with ASCO. I grew up in New York City in Manhattan. My father was a well-known dermatologist. He was my role model. And from the age of eight, I knew I wanted to be a doctor. Nothing else ever crossed my mind. But having seen my father's many interests outside of medicine, I realized from very early that there was much more to medicine than just science. And that really induced me, when I went to college, to major in the humanities, in history, art history, and I actually took the minimum number of science courses to get into medical school. That probably wouldn't work today, but it was the start of my interest in humanism, humanities, and dealing with people outside of the quantitative sciences.  Dave Johnson: So that's reflected in how we all view you, John. You're one of the most humanistic physicians that I know personally. I wonder if you could tell us about your interest in medical oncology, and in particular, as one of the pioneers in the field. I mean, there wasn't really even a specialty of medical oncology until the early 1970s. So, how in the world did you get interested in oncology and what drew you to that specialty? Dr. John Glick: Well, I had two clinical experiences that drove me into oncology. The first, when I was a third year medical student at Columbia PNS, my first clinical rotation in internal medicine, I was assigned a 20-year-old who had acute leukemia, except he was not told his diagnosis. He was told he had aplastic anemia, receiving blood and platelets, and some form of chemotherapy. And I spent a lot of time just talking to him as an individual, not just taking care of him. And we became friends. And he was then discharged, only to be readmitted about two weeks later. And in the elevator, the medical assistant had his admission sheet, and unfortunately, it was facing the patient, and it had his diagnosis, acute leukemia. So he came into the ward and he confronted me. "Why didn't you tell me I had acute leukemia?" Well, I couldn't say the attendees forbade me to do that. So I took what today we would call ‘the hit’, and apologized. But it stimulated me to reflect that honesty with patients was extremely important, and that oncology was just in its infancy. We knew nothing about it. It was not considered even a specialty. I don't think we used the word "oncology."  But that inspired me to take an elective in my fourth year at PNS, at an indigent cancer hospital called the Francis Delafield Hospital. It only took care of indigent cancer patients, and there were wards, twelve patients in a ward, six on each side, and nobody would go see the patients. It was almost as if they were afraid that if they were to touch the patient, they would get cancer. And I started talking to the patients, and they were human beings, but nobody had told them their diagnosis. Nobody had told them if they were terminal. And there were a few patients who were getting a new drug at that time for multiple myeloma called melphalan, and they actually had relief of some of the symptoms, of their bone pain. But I realized that there was a huge void in medicine that I could possibly help to fill.  And that was the era of Vietnam, and so I applied to the National Cancer Institute to become a commissioned officer in the Public Health Service to avoid the draft, to be on a service with, at that time, some very notable oncologists Vince DeVita, Ed Henderson, Paul Carbone. I had read some of their papers, and I was lucky to be accepted. And I was a clinical associate at the National Cancer Institute. And that was life-changing because there every patient was considered to be potentially curable. The advances at that time using MOPP for Hodgkin's disease, C-MOPP for lymphoma, some treatments for leukemia. George Canellos pioneered the use of CMF for metastatic breast cancer. It was an amazing, amazing experience. That was in 1971 to ‘73. Oncology did not become a true specialty till ‘73, but my two years at NCI were formative.  However, I realized that there was something missing in my training. Everybody was considered curable, but I had never seen a patient with metastatic colon cancer, metastatic lung cancer. The radiotherapists there did not like to teach clinical associates, and I knew that there was a place called Stanford. And Stanford had Saul Rosenberg in medical oncology for lymphomas and Henry Kaplan in radiotherapy. So, everybody was going to California, and my wife and I packed up and went to California and spent a year at Stanford, which, combined with my training at the NCI, led me to the principles that guided my career in oncology; humanity, optimism, reality, compassion, and a love for clinical trials.  I was very, very fortunate to be there at the dawn of medical oncology shortly after I decided to go to Penn, which at that time did not have a medical oncologist. In fact, I was the only medical oncologist at Penn for four years and did every consult in the hospital for four years, much to the chagrin of my wife. But I was fortunate to have great mentors in my career: Paul Carbone, Vince DeVita, Saul Rosenberg, Henry Kaplan, among many, many others. And that impressed me about the importance of mentorship because my career would never have been where it was or is without these mentors. Pat Loehrer: John, just to echo what Dave said, you've been such a tremendous mentor for us. Dave and I particularly, you took us under your wings when you didn't know who we were. We were people in the Midwest. We weren't from any place shiny, but we really appreciate that. Dave Johnson: So, John, I mentioned at the very beginning that I met you before I met you, and the way I met you was

Oncology is a rapidly evolving medical field. So how do you keep up with all the advances and updates that are delivered through publications, conferences, and social media? This ASCO Education podcast explores how three oncologists in various settings and stages of their career manage this issue. Our moderator Dr. Adriana Alvarez, a medical oncologist at Cleveland Clinic in Ohio is joined by Dr. Sharad Goyal, a professor and division chief of Radiation Oncology at George Washington University in Washington, DC; Dr. Shruti Patel, an oncology fellow at Stanford University in California; and Dr. Banu Symington, a medical oncologist at Memorial Hospital of Sweetwater County in Wyoming, and adjunct professor in the University of Utah College of Nursing. Each will describe what they do to keep up to date on research advances and guidelines (3:25), how they find time to stay current in their field (7:25) and how they follow developments outside of their area of concentration (13:57).  The speakers have no relevant disclosures.  Resources: Podcast: Cancer Topics - Burned Out? Here's What You Can Do About It (Part 1)  Podcast: Cancer Topics - Burned Out? Here's What You Can Do About It (Part 2)  Podcast: Cancer Topics - Burnout in Oncology: Trainee Perspective  If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed on the podcast page.  Dr. Adriana Alvarez: An oncologist recently described that while sitting on a couch to write an article, by the time he finished his first paragraph, he received six notifications on his iPhone from WhatsApp, Twitter, and other messages. He knows what the dilemma is; you can shut down your phone, but you become worried about missing an urgent call or important update. The oncologist knows that social media is a place to follow friends and colleagues, to discover new presentations, and even debate about them. However, he understands the overload of information that is part of the rapidly evolving field of oncology. On any given day or week, there are research advances and updates in the management of cancer being shared through journal publications, conference presentations, newsletters, social media, and other methods. How does one keep up to date with these advances in oncology?  I'm Dr. Adriana Alvarez, a medical oncologist at Cleveland Clinic in Ohio. In this ASCO Education Podcast, we will examine what various oncology professionals at different stages in their careers and working in different practice settings, namely academic versus community and urban versus rural, are doing to manage the large amount of information influx regarding advances in oncology.  Joining me are Dr. Sharad Goyal, a professor and division chief of radiation oncology at George Washington University in Washington, DC; Dr. Shruti Patel, an oncology fellow at Stanford University; and Dr. Banu Symington, a medical oncologist at Memorial Hospital of Sweetwater County in Wyoming, and adjunct professor in the University of Utah College of Nursing.  Let's start. One of the first questions I have here is how you can describe your current field of focus in oncology. Dr. Patel? Dr. Shruti Patel: My current clinical focus in oncology is in thoracic and gastrointestinal malignancies, while my research interests include clinical trials, liquid biopsy, and diversity, and equity and inclusion.  Dr. Sharad Goyal: My current clinical and research focus is on breast cancer, radiation therapy, as well as radiation therapy with respect to neuro-oncology in the neuro-oncology space. Dr. Adriana Alvarez: What about you, Dr. Symington? Dr. Banu Symington: I'm a general oncologist, medical oncologist, in an extreme rural, I'm considered a frontier practice. I have a special interest in eliminating the social disparity that is represented by rurality, and I'm interested in clinical trials. We are the only Wyoming Cancer Center that opened clinical trials. Dr. Adriana Alvarez: Well, it's all wonderful to hear about you and know a little bit about what your focus of work is, and we come from a variety of backgrounds. How do you feel like you keep up to date with the clinical practice, the research parts with new drugs approval in oncology? You are still in training Dr. Patel. How do you do that? Dr. Shruti Patel: As a millennial, it may come as no surprise that I primarily stay up to date on clinical practice guidelines via Twitter on my phone. I find Twitter to be the best place to learn new information. Just because you don't just get information about the new approvals, but typically experts in the field will weigh in on the trial design, their thoughts on whether it truly will replace the current standard of care or what situations they might use the new approval for, which can really be helpful, especially as a fellow in training. It's helpful context beyond just the information that you get from the approval itself. And then, I also learn about the applications of these new guidelines in the clinic with my mentors, because I am, of course, lucky enough to still be in training where I can gather that information from my attendings. Dr. Adriana Alvarez: Dr. Goyal, what is your preferred method of keeping up to date and learning more about the new treatments and research in your area of interest?  Dr. Sharad Goyal: As opposed to Dr. Patel, I am not part of social media in medicine. Actually, I'm not a part of any social media, whether it's personal or work-related. So I tend to be a little more “old school” with respect to how I ingest information. So, in terms of clinical practice guidelines and new drug approvals, which is somewhat peripheral to my field in radiation oncology, I tend to rely on NCCN guidelines and attendance at tumor boards to receive that information from my colleagues in medical oncology. I believe that with any patient that I see with a malignancy, I do tend to refer to the NCCN guidelines on a regular basis. And if it's a malignancy that I do not see, I have to reference PubMed, UpToDate, and the NCCN guidelines to determine the best course of treatment for that patient. Dr. Adriana Alvarez: What about you, Dr. Symington? Being in the rural area, I can see that you have a variety of situations. How do you keep up to date? Dr. Banu Symington: I guess I'm midway between Doctors Patel and Goyal. I do not follow Twitter, but I belong to a 5000-member online hematology/oncology support group, and we post questions, and local thought leaders will reply. I am in such an isolated location. I don't get the stimulation or the benefit of walking down the hall to a colleague to say ‘What would you do?’ So I am affiliated with the Huntsman and the University of Utah. I've made an effort to join every organ-specific tumor board so that I can hear discussions by disease thought leaders about how they're going to take care of each type of cancer and hearing that week after week, I do absorb it.  Medical oncology is a challenging field because things move so rapidly. I took an 18-month, mostly Sabbatical, as I functioned as a chief of staff at a larger hospital. And in that 18-month period, where I volunteered in a clinic, immune checkpoint therapy arose, and targeted therapies for lung cancer arose and I felt like Sleeping Beauty. I went to sleep in one world, and I woke up in a completely different world of oncology. And it was hard to get back into the drift until I connected with colleagues. I'm an avid reader. I don't sleep much. So I am a member of AMA, ASCO, and ACP, so I get all the print journals. And I have a disorder, an obsessive-compulsive disorder, that makes me have to look through every single journal I get. So print and tumor boards and colleagues.  Dr. Adriana Alvarez: So we are very busy, and the work that we do, the clinical work, trying to keep up to date and training and all that, how do you schedule time to do this, to learn about the research advances and to keep going? Dr. Goyal, how do you find the time? Dr. Sharad Goyal: In general, I do think that in my realm, in my head, I think that there are three processes that have to occur when I incorporate research into my practice. So number one, I have to learn about it. Number two, I have to determine if that's going to help change my practice. And then number three, if I do end up changing practice, I have to implement it. And that involves dealing with my staff. So I'm going to delve into each of those in a little bit more detail. So learning about the advance typically, I learn about things through CME activities. So in one of my roles in our cancer center, I help organize our grand rounds and some oncology-specific courses. Being involved in the organization, helping find speakers really keeps me engaged not only in the organization process, but also in the learning process because I have a vested interest in making sure that the trainees and other faculty that attend my courses are learning and are happy.  Dr. Adriana Alvarez: To organize all these, do you schedule time during your job, outside work hours? Dr. Sharad Goyal: Yes, that is part of my job, which extends outside of work hours. Dr. Adriana Alvarez: Sounds good. Dr. Symington, well, you mentioned that you don't sleep much, you keep up to date, looks more at night. But do you find the time in between patients or during your workday to keep up to date, or is more like a solitude type of time?  Dr. Banu Symington: I forgot to mention a resource that I feel like people should know about, MedNet, which is presented daily with three clinical cases and thought leaders mentioning what they would do. They often introduce research ideas that are not adopted into practice. Since I read, I read about new innovative treatments, but I am not an early adopter, so I wait until they become an NCCN guideline before I would adopt it. So that

The availability and quality of cancer care varies in different parts of the globe. Some locations find it difficult to have proper equipment, access to medications or even trained staff on hand. In this ASCO Education podcast we look how a group of doctors are sharing their skills and experience to set up training programs to help improve outcomes for patients with cancer in Kenya. Our guests will explore the creation of a pediatric oncology fellowship program in Kenya (11:48), how a young doctor found herself interested in improving global health (14:30), and discuss lessons learned that are applicable to health care in the United States (21:07).  Speaker Disclosures Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Dr. Terry Vik: Research Funding Takeda, Bristol Myers Squibb Foundation Dr. Jennifer Morgan: None Resources: Podcast: Oncology, Etc. - Dr. Miriam Mutebi on Improving Cancer Care in Africa Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan (Part 1) Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan Part 2 If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed in the podcast page. Dave Johnson: Welcome, everyone, to a special edition of Oncology, Etc., an oncology educational podcast designed to introduce our listeners to interesting people and topics in and outside the world of Oncology. Today's guest is my co-host, Dr. Pat Loehrer, who is the Joseph and Jackie Cusick Professor of Oncology and Distinguished Professor of Medicine at Indiana University, where he serves as the Director of Global Health and Health Equity. Pat is the Director Emeritus of the Indiana University Simon Comprehensive Cancer Center. Pat has many different accomplishments, and I could spend the next hour listing all of those, but I just want to point out, as many of you know, he is the founder of what formerly was known as the Hoosier Oncology Group, one of the prototypes of community-academic partnerships which have been hugely successful over the years.  He's also the founding director of the Academic Model for Providing Access to Healthcare Oncology Program, which has grown rather dramatically over the last 17 years. This includes the establishment of fellowship programs in GYN oncology, pediatric oncology, and medical oncology through the Moi University School of Medicine in Kenya. Through its partnership with the Moi Teaching and Referral Hospital, over 8000 cancer patients a year are seen, and over 120,000 women from western Kenya have been screened for breast and cervical cancer in the past five years. Pat is also the co-PI of the U-54 grant that focuses on longitudinal HPV screening of women in East Africa. He currently serves as a Senior Consultant of the NCI Cancer for Global Health.  So, Pat, welcome. We have with us today two special guests as well that I will ask Pat to introduce to you. Pat Loehrer: Dave, thanks for the very kind introduction. I'm so pleased today to have my colleagues who are working diligently with us in Kenya. The first is Terry Vik, who is Professor of Pediatrics here at Indiana University and at Riley Hospital. He's been the Director of the Fellowship Program and the Pediatric Hematology-Oncology Program and Director of the Childhood Cancer Survivor Program. He got his medical degree at Johns Hopkins and did his residency at UCLA and his fellowship at Dana-Farber. And he's been, for the last 10 to 15 years, been one of my co-partners in terms of developing our work in Kenya, focusing on the pediatric population, where he helps spearhead the first pediatric oncology fellowship in the country.  And then joining us also is Dr. Jennifer Morgan. Jenny is a new faculty member with us at Indiana University as an Assistant Professor. She, I think, has 16 state championship medals for track and field in high school. I've never met an athlete like that in the past. She ended up going to Northwestern Medical School. She spent time in Rwanda with Partners in Health, and through that, eventually got interested in oncology, where she completed her fellowship at University of North Carolina and has spent a lot of her time in Malawi doing breast cancer research. I don't know of anyone who has spent as much time at such a young age in global oncology.  Dave Johnson: So Pat, obviously, you and I have talked a lot over the years about your work in Kenya, but our listeners may not know about Eldoret. Maybe you can tell us a little bit about the history of the relationship between your institution and that in Kenya. Pat Loehrer: It's really a remarkable story. About 30 some odd years ago, Joe Mamlin and Bob Einterz, and Charlie Kelly decided they wanted to do a partnership in Global Health. And they looked around the world and looked at Nepal and looked at Mexico, and they fell upon Eldoret, which was in Western Kenya. They had the birth of a brand new medical school there, and this partnership developed. In the midst of this came the HIV/AIDS pandemic. And these gentlemen worked with their colleagues in Kenya to develop one of the most impressive programs in the world focused on population health and dealing with the AIDS pandemic. They called it the Academic Model for Prevention and Treatment of HIV/AIDS or AMPATH, and their success has been modeled in many other places. They have many different institutions from North America and Europe that have gone there to serve Western Kenya, which has a catchment area of about 25 million people.  About 15 to 20 years ago, I visited AMPATH, and what they had done with HIV/AIDS was extraordinary. But what we were seeing there in cancer was heartbreaking. It reminded us, Dave, as you remember back in the ‘60s and ‘70s with people coming in with advanced cancers of the head and neck and breast cancers that were untreated. And in addition, we saw these young kids with Burkitt's Lymphomas with huge masses out of their jaws. And seeing that and knowing what was possible, what we saw in the States and what seemed to be impossible in Kenya, spurred me on, as well as a number of other people, to get involved. And so, we have built up this program over the last 15 and 20 years, and I think it's one of the most successful models of global oncology that's in existence.  Dave Johnson: That's awesome. Terry, tell us a little bit about your involvement with the program at Moi University.  Terry Vik: Sure. So, I took an unusual path to get to Eldoret because I started off in work in signal transduction and protein kinases, then morphed into phase I studies of kinase inhibitors that was happening in the early 2000s. But by the end of the decade, Pat was beginning to establish oncology programs in Kenya. And because half the population is children and there were lots of childhood cancers, and many of them can be curable, he mildly twisted my arm to go with him to set up pediatric oncology in Kenya. And through his help and Matt Strother, who is a faculty member on the ground, establishing that, I first went in 2010 just to see how things were running and to see all the things that Pat had recognized as far as things that needed to be done to make Eldoret a center for cancer care.   And so, the last 13 years now, I've been working, going anywhere from one to four times a year to Kenya, mainly helping the Kenyans to develop their medical care system. Not so much seeing patients or taking care of patients, other than talking about best practices and how we do things in the US that can be readily translated to what's going on in Kenya. And so, we've been able to establish a database, keep track of our patients in pediatric oncology, recognize that lots of kids are not coming into care, not being diagnosed. There's a huge gap between numbers who you would expect to have childhood cancer versus the numbers actually coming to the hospital. As the only pediatric treatment center for a catchment area of 25 million, half of whom are under the age of 20, we should be seeing a lot of kids with cancer, but we are probably only seeing 10% of what we would expect.  So, myself, many of my colleagues from Indiana University, as well as colleagues from the Netherlands Princess Maxima Hospital for Pediatric Cancer, we've been partnering for these past 13 years to train Kenyans to recognize cancer, to have treatment protocols that are adapted for the capabilities in Kenya, and now finally starting to show real progress in survival for childhood cancer in Kenya, both in leukemias, lymphomas, and solid tumors, with a fair number of publications in Wilms tumor and Burkitt lymphoma and acute lymphoblastic leukemia. So, it's been really heartening, I think.  I tell people that the reason I go to Kenya studying signal transduction and protein kinase inhibitors in pediatric cancer, I can maybe save a couple of kids over a career by that kind of work. But going to Kenya to show people how to find and treat kids with leukemia, I'm literally seeing the impact of hundreds of kids who are alive today that wouldn't be alive otherwise. So, that's really been the success of pediatric oncology there. Dave Johnson: Is the spectrum of childhood cancer in Kenya reflective of what we see in the States, or are there some differences? Pat Loehrer: It really is surprisingly similar. I think the only thing that– Well, two things that are more common in Kenya because of the so-called ‘malaria belt’ and the association with Burkitt Lymphoma, there's a fair number of kids with Burkitt’s Lymphoma there. Although, as mosquito control and malaria control has improved, actually, the numbers of cases of Burkitt’s have been dropping, and a lot of cancers were sort of hidden, not recog

Clinical trials are essential to progress in medicine, but racial and ethnic minorities are frequently underrepresented in such studies. In this ASCO Education podcast episode, we will examine this issue with Dr. Carol Brown, gynecologic cancer surgeon and Chief Health Equity Officer at Memorial Sloan Kettering Cancer Center, Dr. Ana Maria Lopez, Professor and Vice Chair of Medical Oncology at Sidney Kimmel Medical College and former Chair of ASCO’s Health Equity Committee and Mr. Ted Bebi, Innovation Manager at Medidata Solutions. They discuss how diversification of clinical trials contributes to health equity (4:03), barriers to participating in clinical trials (14:37), and what clinicians and trial sponsors can do to improve participant diversity in clinical trials (20:25).  Speaker Disclosures Dr. Carol Brown – None Ted Bebi: Employment – Medidata (a Dassault Systèmes company); Stock and Other Ownership Interest – Pfizer, Eli Lily, Abbvie, Merck, BMY        Dr. Ana Lopez - None Resources ASCO-ACCC Initiative to Increase Racial & Ethnic Diversity in Clinical Trials Journal Article: Increasing racial and ethnic diversity in cancer clinical trials Journal Article: Representation of minorities and women in oncology clinical trials Podcast: Impact of Implicit Racial Bias on Oncology Patient Care and Outcomes ASCO-ACCC JustASK Training Program If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Dr. Carol Brown: Welcome to the ASCO Education podcast. I'm Dr. Carol Brown, a gynecologic cancer surgeon and the Chief Health Equity Officer at Memorial Sloan Kettering Cancer Center. Our guests and I will be exploring the problems and solutions with regards to racial disparities in clinical trials.   A necessary element for conducting clinical trials is, obviously, the enrollees or participants. Racial and ethnic diverse groups are frequently underrepresented in clinical trials, despite having a disproportionate burden for certain cancers. In addition, there is increasing evidence that a person's individual genetic makeup may determine the level of toxicity or efficacy of a new cancer drug specifically. Therefore, when we don't have enough diversity in our cancer clinical trials, it can really undermine the generalizability of our results. And so, to address this gap, in its recent updated guidance to industry, the US Food and Drug Administration stated that enrollment in clinical trials should reflect the diversity of the population who ultimately use a treatment.   In 2022, ASCO and the Association of Community Cancer Centers issued a joint statement recommending that anyone designing or conducting trials should complete recurring education, training, and evaluation to demonstrate and maintain cross-cultural competencies, mitigation of bias, effective communication, and a commitment to achieving equity, diversity, and inclusion.   Joining me to discuss this important topic today is Dr. Ana Maria Lopez, who's the Professor and Vice Chair of Medical Oncology at the Sidney Kimmel Medical College. And she's the former Chair of ASCO's Health Equity Committee. Our second guest is Mr. Ted Bebi, Innovation Manager at Medidata Solutions. His research explores underrepresentation of black patients at clinical trials and how diversity impacts clinical trials.  Participant disclosures for this episode are listed on the podcast page.  So why should we care about improving diversity in clinical trials? Dr. Lopez? Dr. Ana Maria Lopez: We are clinicians. We are wanting to take care of our patients as best as possible, and we can only do that if our studies include everyone. An example that I often think about is the concept of airbags began in 1953, and in 2008, the National Highway Traffic Safety Administration came out and said, “You know what? We should be testing airbags on small female crash test dummies because otherwise, we don't know that these airbags will be safe.” And in fact, there were data that the airbags that existed put women and children at a much higher risk for injury or death. So, we want to be ahead of that curve, and we want to allow the best possible treatment. Dr. Carol Brown: So, Mr. Bebi, what would you say about how we could improve diversity in clinical trials? Ted Bebi: So I really like the example of the airbags that Dr. Lopez brought up because it makes it clear when building a product it's important to test the product in a representative sample of the population that will ultimately end up using it. It's the same with products like medications. If you want an efficacious drug, you should test it in the appropriate population. It's what constitutes good science. Additionally, adequate diversity in clinical trials is also important because it's ultimately an issue of health equity and providing fair access. Dr. Carol Brown: Could you kind of go on from there and talk about, specifically, how does diversifying the group of people that participate in clinical trials actually translate into increasing health equity?  Ted Bebi: Well, participating in a clinical trial is a form of receiving health care. Often, we are talking about patients for which a clinical trial might be their last resort. And even if not, participating in a clinical trial means gaining early access to potentially life-changing drugs that could become the new industry standard and doing so at no cost. So, you're receiving care and follow-up from some of the best specialists in the field. So having fair access to this opportunity for all patients is definitely a health equity issue. Dr. Carol Brown: Great. Dr. Lopez, how would you answer that question about how does diversifying clinical trials contribute to health equity? Dr. Ana Maria Lopez: Yeah, no, I think I agree with everything that Mr. Bebi said. In addition, I think we have to remember that diversity is more than race. Race is truly a social construct. We need to think about gender. We need to think about age, the whole lifespan, and people are living longer. How we metabolize medications at different time points in our life may vary. So, lots of different factors that we can consider when we think of diversity. But the gold standard is really: Are folks getting the best outcome possible? And as long as that metric is not being reached, we need to be thinking of how can we facilitate that. Dr. Carol Brown: So, Dr. Lopez, you brought up this concept that health equity is really the best outcome possible. Could you comment a little bit about how do we know, particularly in cancer, what is the best outcome possible? So how do we determine what the reference is for that, so we can figure out whether our patients are actually getting health equity? Dr. Ana Maria Lopez: Sure. So, we use different time points. We can look at relapse rates, survival rates, and of course, part of that may be comorbidities. Certain comorbidities that people have may impact their cancer treatment outcomes. So, it is complex, but it is important for us to take a look contextually at what the patient's risk is and what the patient's outcome would be. Dr. Carol Brown: We can kind of all agree that when we're talking about equity, it's getting the best outcome for everybody, no matter what they're bringing to it. And I really like your comment, Dr. Lopez, about race being not only the only factor but remembering that it is a social construct. If you could add to that, Mr. Bebi. Ted Bebi: We're talking a lot about diversity in clinical trials in terms of race and ethnicity, and that is something that is ultimately very important. But we're talking about diversity in all sorts of aspects. We're talking about diversity with age. We're talking about diversity with sex, with socioeconomic aspects because we often use race as a proxy for other things that might be going on in patients’ lives. And we need to consider all of this part of diversity in clinical trials because once the drug is out in the market, it will be an intersection of potentially all of those identities and many things going on in their life that might affect how they respond. So, when we're thinking about race as a diversity point, we might be using it as a proxy for a specific type of individual, a specific patient journey that we want to make sure to include. It's not necessarily that race is the end-all, be-all measure of diversity; it's that we want to capture the true patient experience for that disease. Dr. Ana Maria Lopez: What I think is also really interesting is how we collect the data. And some of what the last couple of years have taught us is that folks may not trust our healthcare systems, and so folks may not be willing to say, ‘I am X, Y, or Z,’ which certainly puts us a little bit in the void. So how important it is for us as clinicians, as researchers, to be part of creating an environment where patients can feel that ‘Yes, I can trust and I can share, and I can say, this is who I am,’ because that could impact clinical care. Dr. Carol Brown: So, acknowledging that race is a social construct and that it really is used as a surrogate for other social determinants of health and other factors that affect health, and again, really acknowledging what you said, Dr. Lopez, that even asking people to identify their race is extremely problematic. But given what we do know and what our experience has been in the clinical trial world, first, Mr. Bebi, could you comment about what has been your experience and your research with the current state of participation by diverse racial and ethnic groups in clinical trials in the United States? What have you found in your research?  Ted Bebi: Recently, at Metidata, we published a paper where we looked at the state of black participation in clinical trials. We found the level at which you look at the data really matters. For example, when we looked at racial diversity

For some, pursuing a medical career is an all-consuming passion. What do you do if you have two? In this ASCO Education podcast, we look at the influences that propelled Dr. Lisa Rosenbaum to become a practicing cardiologist at Brigham and Women’s Hospital in Boston and a national correspondent for the New England Journal of Medicine. Dr. Rosenbaum will explain the family legacy that impacted her choice to pursue medicine (1:46), her discovery of the love of writing (5:02) and what prompts her to write about specific topics (15:53). Speaker Disclosures Dr. Lisa Rosenbaum: None Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Resources:  Gray Matters: Analysis and Ambiguity by Lisa Rosenbaum, MD Podcast: Oncology, Etc. - In Conversation with Dr. Peter Bach (Part 1) Podcast: Oncology, Etc. – In Conversation with Dr. Peter Bach (Part 2) If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Disclosures for this podcast are listed in the podcast page.  Pat Loehrer: Welcome to Oncology, Etc. an ASCO Education Podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University. Dave Johnson:  Hi, I'm Dave Johnson, a medical oncologist at the University of Texas Southwestern in Dallas, Texas. If you're a regular listener to our podcast, welcome back. If you're new to Oncology, Etc., the purpose of our podcast is to introduce listeners to interesting people and topics in and outside the world of oncology, hence the "etcetera" in our name. Today's guest is an example of the "etcetera" aspect of our podcast. Dr. Lisa Rosenbaum is a practicing cardiologist at the Brigham and Women's Hospital in Boston and a member of the Harvard Medical School faculty. She's a highly respected national correspondent for the New England Journal of Medicine. Dr. Rosenbaum began her writing career while she was still an undergraduate at Stanford. She later attended med school at the University of California, San Francisco, completed an internal medicine residency at the Mass General Hospital in Boston, and a cardiology fellowship at Weill Cornell in New York. She spent an additional year of fellowship at The New England Journal, where she learned about writing, reporting, and investigative journalism. Subsequently, she was hired for an academic position at Brigham and presented with an opportunity to write on a regular basis for The New England Journal. She's written on a whole variety of topics, ranging from physician burnout to cognitive bias, resident duty hours, conflicts of interest, vaccine hesitancy, and many other topics.  So, Lisa, thank you for joining us today. We're very excited to have you on the program.  Dr. Lisa Rosenbaum: Thank you so much for having me. Dave Johnson: Well, perhaps we could start by asking you to just tell us a little about your background and your family. Dr. Lisa Rosenbaum: I grew up in Portland, Oregon. My parents are both physicians. My father is a rheumatologist and my mom is a cardiologist, and now my sister is also an endocrinologist. And we have several family members who are physicians, including my grandfather, who was also a rheumatologist and a writer and played a pretty pivotal role in my life, both in terms of my decision to become a physician and also a writer. When he was in his 70's, he got laryngeal cancer and he was treated with radiation therapy and cured. But after, he wrote a book about the experience of being a patient called A Taste of My Own Medicine, which I think was published in the late 80's. It's an autobiography. And then in the early 90's, Disney bought the rights to the book and made it into the movie The Doctor, starring William Hurt. He has a cameo, actually, and apparently it took him like 17 takes just to get it right, to wave his hand when he's sitting in the waiting room.   That was a pretty formative experience in my life, because basically he ended up, after writing that book and, you know, having a lot of success with it, wanting to write another book. And by then he was in his late 80's, and he ended up getting Parkinson's disease, which steadily progressed. He died at 94, so he lived a long, good life. But when I got into medical school, he decided he wanted to write a book with me and that it was sort of the follow up to A Taste of My Own Medicine, because he sort of recognized medicine's shortcomings in the book and asked a lot of questions, but he would always say, "I have more questions than I have answers." And when I got into medical school, he had this idea that we were going to come up with all the answers and make medicine as wonderful as it had once been for him. So obviously that was a big part of my life, both in terms of my career as a writer and also my career as a doctor. Though I think I really never questioned whether or not I wanted to be a doctor. That just sort of seemed so obvious to me as a kid that the work was so meaningful. And I don't know, there's something about growing up where everywhere you go, people tell you how one of your relatives made their lives better. That's pretty inspiring, as a kid.   Pat Loehrer: It's interesting that both your parents were physicians, but you claim that your grandfather is the one that got you into medicine. But I think your early career, I think you were actually kind of focused on writing and writing creative fiction, and there was another event in your life that kind of turned you back over to medicine too, right? Dr. Lisa Rosenbaum: Right, right. And I don't want to not give credit to my parents. They played a huge, wonderful role in my life as well, and they still do.  So anyway, I did take a detour in my career. So, in college I ended up, the fall of my junior year, taking a creative writing class. I'd done all the pre-med requirements by then and probably like many pre-meds, it felt very robotic to me. It's also, you're surrounded by all these people who are really ambitious, and you can feel like you're not very good, right? I remember I made a B-minus on my first organic chemistry exam, and I called my mom crying, and I was like, "I'm not going to be a doctor. This is a disaster." So all of a sudden, once I had gotten through those classes and I took this creative writing class, it was just this transformative experience for me because it was intensely creative. And I've always been just really interested in people, like what makes people do what they do, and character. I am just so fascinated by people's characters.  But the other part of the creative writing classes that I loved so much was just the sense of community. So you go from this setting where you're all sort of pitted against one another in these classes, and then you're in this place where everybody's trying to help each other and you're learning about each other through writing because we're all really just like writing about ourselves, even when we pretend otherwise. And I made some of the best friends of my life who've gone on to have actually remarkable writing careers. So sort of on a whim because it was so enriching for me and I felt like I couldn't live without it, I applied for MFA's in Creative Writing in my senior year, and I got rejected everywhere but waitlisted at Columbia. And then I got in. So I moved to New York in 2001, basically a week before September 11th, and I truly fell apart. Not in a way that I regret at all now. I think that a lot of us, when we are not productive, feel like our time is wasted. And I don't think I wrote a word that entire year. Like, I got really depressed and I just spent a lot of time wandering the city and I ate a lot of bagels, but I was really sad. I spent a lot of time downtown, like, looking at the faces of all these people who had died. And it was so unfathomable to me. And I wasn't able to use writing to cope with it as I might be able to now. I think I was just too young. And I had challenges with my writing professor who sort of felt like we shouldn't be writing about that.  And so I ran away from writing. I mean, I dropped out of creative writing school and went to medical school, and that was clearly the right move. More than anything in my life, I love being a doctor, so I don't regret that at all. And I think it actually was really helpful to me to recognize that I'm not cut out to just be a writer. I need to be inside people's lives, and there's no better way to do that than as a physician. And writing is this extra bonus that I have still that helps me just like it did when I was writing fiction, sort of try to understand the world. But I don't think I could function if I didn't get to take care of patients. And that became clear when I was 22 years old, essentially.  Dave Johnson: So, Lisa, you did this fellowship at the New England Journal of Medicine. Can you tell us about that? What was that like? And how much influence did that have in your current position?  Dr. Lisa Rosenbaum: It was awesome on so many levels. I think the first was that I really loved listening to people talk about science. That was new for me. And the rigor of the conversations at The Journal is really just hard to describe, and I just felt like I was like a kid in a candy shop. I'm interested in science, obviously, as a practicing physician, but I'm interested in science always in these meta ways. I'm interested in how we communicate science and the words we use and the conflicts that we focus on and those that we don't. And so much was always going on in my mind. ‘I was like, oh, my God, these are the data that are going to shape our practice. And then you have, like, a bunch of humans making these decisions.’ And so that was inherently fascinating to me.  And the other thing that was really transfor

Advanced practice providers (APPs) are a key component to effective team-based care, but what is it that our APP team-members can do in an oncology practice? Join the Co-hosts of the APP podcast series, Todd Pickard (MD Anderson Cancer Center) and Stephanie Williams (Northwestern University Feinberg School of Medicine), along with guests Wendy Vogel (BroadcastMed/APSHO)) and Tammy Triglianos (University of North Carolina Basnight Cancer Hospital), as they highlight the services and examples of what APPs in oncology can do, their role as an APP in team-based care, if and how they bill for their services, and how they are reimbursed.  Speaker Disclosures: Stephanie Williams: Consultant or Advisory Role – CVS Caremark Tammy Triglianos: Consulting or Advisory Role – Pfizer Todd Pickard: No relationships to disclose Wendy Vogel: No relationships to disclose  Resources: Podcast: Advanced Practice Providers - APPs 101: What and Who Are Advanced Practice Providers (APPs)? Podcast: Advanced Practice Providers – An APP’s Scope of Practice Advanced Practice Providers - APPs 101: Physicians Assistants (PAs) and Advanced Practice Registered Nurses (APRNS) in Oncology If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT The disclosures for guests on this podcast can be found in the show notes. Dr. Stephanie Williams: Hello, everyone, and welcome back to the ASCO Education podcast, and our fourth episode of the Advanced Practice Providers series. I'm Dr. Stephanie Williams, a medical oncologist, and your co-host for the series, along with physician assistant Todd Pickard. We’d also like to introduce you to our guest panelists today. Returning guest, Wendy Vogel, along with Tammy Triglianos. We’ll take a moment to let them introduce themselves, starting with Wendy. Wendy Vogel: Hi. Thanks so much for having me today. I'm Wendy Vogel. I'm an oncology nurse practitioner by trade, and I am the Executive Director of APSHO, the Advanced Practitioner Society for Hematology and Oncology. And thanks for having me here today. I'm really excited to be here.  Dr. Stephanie Williams: Tammy.  Tammy Triglianos: Hi, everyone. Thank you for having me. And I'm excited to join this group for our conversation today. I'm Tammy Triglianos. I am a certified oncology nurse practitioner practicing in North Carolina. My career has been dedicated to caring for oncology patients, even starting out as a nursing assistant and then as a registered nurse practicing in a variety of settings. I've been a nurse practitioner for almost 20 years now, with the past 15 specializing in GI medical oncology.  Dr. Stephanie Williams: Thank you.  Todd Pickard: Thanks, everybody, for being here today.  Dr. Stephanie Williams: In today's episode, we will be highlighting the services and examples of what advanced practice providers in oncology can do and describing if and how they bill for their services and how they are reimbursed.  So let's get started. Wendy and Tammy, I'm starting in my clinic, 8:30 in the morning. We have a full panel of patients, patients who just need reassessment, chemotherapy prescribed, reevaluation, bone marrow biopsies, test results. How do we work together to see, as a team, these particular patients, or in other words, what can you do to help me through my days as an oncology practitioner?  Wendy Vogel: Wow, that’s a great question to just jump right in and start with. I’m excited to talk about that. Well, I think that, you know, as we always are talking about our team approach, we would look at that schedule. And hopefully, the AP and you have their own schedule so that we're able to divide and conquer and be able to accomplish that schedule, see all the patients in the most efficient manner possible. Hopefully, I've looked at all my patients beforehand and see if there's anything that I need to collaborate with you on. Looking at our labs, you know, maybe scans, talking about any changes in plans that we might anticipate together, and so on.   Tammy, would you do the same?  Tammy Triglianos: Yeah, I’d like to echo your point, Wendy. Having independent schedules, I think, makes for a more efficient workflow in the clinic. And in my practice we have a team meeting with our clinical pharmacist, physician, myself, and our nurse navigator, and review last week’s and even prep for the upcoming week, trying to anticipate and make sure people are set up and orders are in, and we're prepared for the week to come. Day of, as you know, can get pretty hectic. But since we've done a lot of that prep work, I think it makes for the unknowns that pop up in clinic easier to connect with each other, with my physician and other team members.  Todd Pickard: I agree. I think the great thing about how physicians and APPs work in teams is that the team can decide what's best. I have done everything from having my own independent template so that I have patients that I'm responsible for to a general template where the physician and I just divide and conquer at the beginning of clinic, and we say, “Okay, you see these patients, I'll see these patients, and we'll back each other up if we need to.” All the way to seeing every single patient along with the physician when we are seeing a lot of news and consults, very complex, very acutely ill patients. And we basically just work as a team the entire day on everything.  So it's really interesting about the conversation that I think we'll end up doing today is the “what” versus “how.” What APPs do is– really, honestly, APPs can do anything and everything unless a state scope of practice or an institution's policy specifically says they can't. That's the good news is that we pretty much can do everything but the “how,” that's a really interesting question because a lot of different things come into play. Position preferences, which could be influenced by their own personal experience or their own personal preferences of style versus, you know, having a misunderstanding of what APPs can and can't do. Then there's the institutional policies and the state scope of practices that come into play. So I think this where we’ll end up spending some time today.  And, you know, Stephanie, maybe we could start the conversation with you a little bit around physician preferences and what your experience has been, and some of the things that you’ve noted around the physicians as part of this team.  Dr. Stephanie Williams: I’ve worked with APPs, both inpatient and outpatient, and I think it is very important to have that team-based approach. Patients really appreciate that, knowing that there is always a provider, someone there that they can turn to. And I think that’s one of the great things about APPs is they always seem to be there for patients to turn to and for our nurses to turn to, to get help too. Both our clinic nurses, our infusion nurses, and our inpatient nurses really appreciate having that extra clinical provider available to them. I think as a physician, during my day, what I would like to see is us getting through our panels of patients, whether we’re together, which is not as efficient as if we’re independently seeing patients, but also help with things like procedures that need to be done on patients, phone calls at the end of the day, peer-to-peer reviews in order to get either medications or tests done for our particular patients. Filling out forms, no one likes doing that. No one likes filling out disability forms or other insurance forms, but those are all things that we all need help with in terms of doing. Ordering consults, seeing new patients together. I work in the transplant field, so they’re complicated patients, so it actually is very helpful to have, to see a patient with your advanced practice provider so that you can come up with a treatment plan together that you know you can then follow throughout the course of hopefully that patient's treatment and recovery. Chemotherapy orders is another place that we need, that can be very valuable, whether it's the initial chemotherapy order, which were usually the physician or pharmacist initiated, but those follow-up chemotherapy appointments or problems in the infusion clinic are also helpful areas.  There are some physicians, though, who want to have an APP simply as their scribe, to follow them around in clinic and to then begin whatever orders they feel is appropriate for that particular patient. That is not the most efficient way to see patients, particularly when you have a large panel of patients that you have to see.  Wendy Vogel: Exactly. It really isn't. I will just tag off something you said about the AP being the scribe. That's probably one of the most expensive scribes that a physician could employ, and what a better use of our time is to not be a scribe. You know, there are other people who could really efficiently be a scribe better than the AP, and the AP could actually be seeing patients and gaining reimbursement for the practice.  Tammy Triglianos: An additional comment on team-based care. I work with a physician where we alternate visits, and I think that has really worked well in establishing a relationship with patients. We both have very high touch points with the patients, very involved, and patients feel like there's that team that's always available because always one of us is usually available. Dr. Stephanie Williams: How long did it take you all, all three of you, to develop that relationship with your physician colleagues to work tightly in a team? Todd Pickard: That's really a great question, Stephanie, because I think one of the strengths of the relationship is that level of trust and comfort and not really to view it as a hierarchical relationship, but really a team. We're there for each other. And you know, that depends, you know, there’s personalities involved, people’s previous experience, you know. I

"Various places on the globe lack the proper knowledge, infrastructure and workforce to adequately treat cancer. In Africa, one doctor is focusing her efforts to change all that. This ASCO Education podcast spotlights Dr. Miriam Mutebi, the first female breast surgeon in Kenya. One of Dr. Mutebi’s goals is to improve women’s health and cancer care in Africa and includes attaining her pilot’s license to reach remote areas of the continent. Dr. Mutebi reflects on her life growing up in Kenya (1:21) and her inspiration for getting into medicine and pursuing what was at the time a male-dominated specialty (5:07). She also details how cancer care has improved in Kenya in the last decade (12:49) while there are ongoing challenges of working in low-resource settings (23:25). Speaker Disclosures Dr. Miriam Mutebi: None Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical Resources: ASCO Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan (Part 1) ASCO Podcast: Oncology, Etc. – Global Cancer Policy Leader Dr. Richard Sullivan (Part 2) If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT Pat Loehrer: Welcome to Oncology, Etc. an ASCO Education Podcast. I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University. Dave Johnson: And I'm Dave Johnson, a medical oncologist at the University of Texas Southwestern in Dallas, Texas. Pat, we have a terrific guest today that ties in very nicely with your interest in global health. I'd love for you to introduce her. Pat Loehrer: Thanks, Dave. Battling cancer is truly a global effort, both in research and in treatment. However, there are various degrees of quality in these fields, depending on the economic health of a particular region. Our next guest is trying to optimize cancer care in Africa. We're very excited to talk to her. Dr. Miriam Mutebi is one of the most prominent cancer doctors in Africa. Dr. Mutebi is the first female breast surgeon in Kenya, and she's currently assistant professor in the Department of Surgery at the Aga Khan University in Nairobi, Kenya. She's on the board of directors for the Union of the International Cancer Control. She has trained and studied at top hospitals in New York and South Africa. Dr. Mutebi is so focused on increasing women's health in Africa that she's trained to be an airplane pilot in order to connect with hard-to-reach areas. Disclosures for this podcast are listed on the podcast page. Thank you so much, Dr. Mutebi, for joining us from Kenya. Can you start off by telling us a little bit about what it was like growing up there? Dr. Miriam Mutebi: I grew up in Nairobi, which is a pretty urban setting to grow up in. So, most of my childhood was spent…I think it was probably a much simpler time where, you know, you would play in the street, go off to somebody's house, spend the rest of the day there and come back at the end of the day. But in terms of growing up, I think I was one of those super nerdy kids, for want of a better word. One of the sorts of things that got me interested in reading and learning and challenging myself was actually my dad. Because what would happen was we had to go to school, I would say almost about 30 kilometers bus ride, and my dad would be like, “Well, if you're on the bus for that long, you can as well, you know, carry a book and made it nice and exciting.” So I remember sort of discovering the library at my primary school and going like, “My word!” Because you get access to all these different experiences and worlds. I mean, you're going in and reading, you know, The Chronicles of Narnia, you're reading about Enid Blyton and different experiences, you're reading all these different worlds and getting to, you know, identify to some extent with the core values that exist. It doesn't matter where the books were centered. And so that for me was an almost, I would say, idyllic growing up, because for me it was like, “Yes, books, check; running around, check.” That's, I think, what I remember most about my childhood. Dave Johnson: It sounds like your father was a powerful influence in your youth. Can you tell us more about your father? Dr. Miriam Mutebi: Sure. My dad, how old is he now? He's going to turn 74. One of the things that he always says, “It costs you nothing to be kind.” And so he would generally– Sorry, I'm just going to stop a little bit. I'm getting weepy. Dave Johnson: I'm sorry. Dr. Miriam Mutebi: It’s okay, it's okay. Shame. Dave, you pushed the button. Dave Johnson: It's not our intent to push a button. It sounds like your dad's a wonderful person. Dr. Miriam Mutebi: No, it's fine. Pat Loehrer: Both Dave and I have daughters, and we feel the same way. So as weepy as you're getting, I can guarantee you that he's going to feel the same way on the other end. Dr. Miriam Mutebi: No, it's just that he hasn't been well recently, so it’s just– Dave Johnson: Oh, I’m sorry. Dr. Miriam Mutebi: Yeah. Okay, cool. Let me see if I can stop getting a little weepy. Yeah. So one of the things that he frequently says is that it costs you nothing to be kind, and I think that's one of the things that he sort of instilled in us that you need to think beyond yourself. You always need to sort of think about what is the other person going through and how can I help to make it better. Now, my dad, he has a really interesting sense of humor. I think it's where I get my cheesy humor from as well. But he always talks about what we call the 11th commandment, which is, don't take yourself too seriously. And so I think that was part of the grounding steps that he sort of helped to instill in us because he was working– I mean, sort of looking back, our parents, I would say, got married at a very young age and had several kids that they were raising. And sort of looking back, you're thinking they were probably just doing the best that they can, right? But I think he did a fairly decent job, I hope. Dave Johnson: So, Miriam, when did your interest in medicine begin, and who was the inspiration for that? Or if there was someone that inspired that? Dr. Miriam Mutebi: At the end of high school, I remember I wanted to do five or, rather, was it six different things. And so I wanted to do medicine, I wanted to write, I wanted to do architecture, I wanted to do law, I even forget what the other things were. There was like two other things on my to-do list. And I think part of the genesis of that was because, as part of the high school training that we go through, we had to do the international sort of baccalaureate, and what that entails is we have to do components of creativity, action, and service. And so at the end, I'm like holding back to father dearest, and I'm like, “Dad, I have six different things I want to do, and I don't really know about.” And he was like, “So why don't you spend a bit of time, sort of just going through each of those, like shadowing these different specialties?” And so we managed to track down his lawyer friend, spent time in the hospital, spent time in the pharmacy, just shadowing the pharmacist. I actually went to work briefly for a publication house. Eventually– Oh, yes, in architecture as well. So then I managed to narrow it down to, “Yes, okay, I want to do medicine, and I want to write.” And so I went back to my dad and said, “Dad, okay, I have two things I want to do.” And my dad was like, “Well, if you do medicine, you can write. But if you write, then you might not necessarily be able to do medicine.” So that's how I sort of wandered into medicine. Although I still say there's still the great African novel waiting to get out. But again, with medicine, I think I'm guilty of what we call ‘end of rotationitis’, where at the end of the day, you finish a rotation, and you're like, “I can do this. I can do this.” So I think going through different rotations– I think for me, the drive– Well, the slow narrowing down to surgery was really around, unfortunately, the time when we were doing our rotations, and this was just really at the start of the 2000s in Kenya. And the challenge around that time was we're really just at the tail end of the HIV epidemic, and not everyone had access to antiretrovirals. And it was an incredibly harrowing time, I would say, for the healthcare profession, just because there was still a lot of stigma around HIV. And what was happening was that we would go to the wards and find patients had been abandoned. And there was a general sort of pervasive sense of hopelessness because people didn’t have access to the medication, they’d been abandoned, and unfortunately, not much was being done in terms of active management to patients. Whereas then that was like on the 7th floor, and then you would go four floors down to the surgical ward where patients come in, they’re bleeding; you take them to OR, they get better, you send them home. And so, for me, the timing was like, “I need to do this. At least I could see where I was making an impact.” And so that’s sort of how I wandered into surgery. And I’m sure, as I said, with, of course, the developments now, the experience, of course, for medical rotations, they're entirely different, but that’s how I sort of ended up in surgery. But then, how I sort of found myself in breast surgery was actually because– for me, what stood out about my breast rotation was really looking at what we were reading in the textbooks, which was breast cancers, the disease of the sixth and seventh decade and a “poster child” for this is the elderly nun who’s never had any children, who’s had this prolonged [inaudible]. And I’m sitting there and looking at the clinic, and I’m like, “These patients are in their 30’s and 40’s. All of these traditiona

"Battling cancer takes place in many parts of the world and our next guest has led initiatives to do just that. In Part Two of this Oncology, Etc. Podcast episode, Professor of Cancer and Global Health at King’s College London Dr Richard Sullivan shares with us his research into cancer care in conflict zones around the world (0:58), his thoughts on “colonial” cancer research (5:50), his advice to people interested in pursuing a career in global oncology field (10:08) and using “pooled procurement” as an innovative approach to cancer care (11:13). Participant Disclosures Dr. Richard Sullivan: Honoraria – Pfizer; Consulting or Advisory Role – Pfizer Dr. David Johnson: Consulting or Advisory Role – Merck, Pfizer, Aileron Therapeutics, Boston University Dr. Patrick Loehrer: Research Funding – Novartis, Lilly Foundation, Taiho Pharmaceutical If you liked this episode, please follow the podcast. To explore other episodes, as well as courses visit https://education.asco.org or contact us at education@asco.org. TRANSCRIPT The disclosures for guests on this podcast can be found in the show notes.  Pat Loehrer: Hi. I'm Pat Loehrer, director of Global Oncology and Health Equity at Indiana University. I'm here with Dave Johnson, a medical oncologist at the University of Texas Southwestern in Dallas, Texas, and a friend of mine. This is the second half of our Oncology Etc. conversation with the professor of cancer and global health at King's College in London and the director of the King's Institute of Cancer Policy and the co-director of the Conflict and Health Research Group, Dr. Richard Sullivan. In part one, we chatted with Professor Sullivan about his international travels as a child to his transition from biochemistry and finally to a great career in health policy and research. Today we're going to continue our conversation with Professor Sullivan by asking him about his insight into the current state of the progress in global health care. Richard Sullivan: Conflict and fragile populations around the world are sadly growing. They're unique ecosystems for a whole variety of reasons. I think fundamentally, though, to do research in those systems requires a huge amount of sensitivity and experience and expertise because you're dealing with the most vulnerable of the most vulnerable. And then, of course, whatever research you do, you're constantly thinking in the back of your mind how you then tie this into any form of impact. There is a tendency, often with research in these populations, that the research is just done for the researcher's sake rather than actually being utilized to help improve those lives you're actually involving and studying. But I admit it's a very tricky area to work in. Cancer in conflict populations, a particular interest is a relatively new domain. It's only really been around for the last eight to ten years for a variety of very understandable reasons. Let's be honest, 30 years ago, cancer was not a significant factor in humanitarian conflict operations. You were dealing with demographically untransitioned societies, much younger. Really the group one, infectious diseases, child and maternal mortality, et cetera, were the primary foci. That still is the case. But what we're seeing now is much more transitioned populations being impacted by conflicts. And you think about in Mexico, in the Narco Wars, Syria, Iraq, even Afghanistan, and all of those have changed dramatically the nature of how care is delivered and how patients move. And we call these new therapeutic pathways, and we consider them kind of post-Westfalian. We're not talking about cancer care anymore that's boundaried within nation states. Patients moving across national lines, we have patients moving in pathways which are absolutely unique and we've never experienced or seen before in the high-income West. And that means you have to have a different paradigm for care and a different paradigm for building cancer control systems. And I guess for the last ten to fifteen years that's what we've really been interested in is this dynamic of conflict populations and how you deliver care and who delivers it. And there, of course, you're talking with a very mixed act, a bunch: humanitarian organizations, the big NGOs, the ICRCs, Medecins Sans Frontières. You're talking about the militaries in many countries. The militaries are very powerful in many countries in terms of providing care. And then finally there is, of course, the health services or systems that exist to varying degrees in the individual countries infected by conflict. So our program really tries to understand how you strengthen health systems per se in these conflict populations. And obviously, my particular interest is in cancer and palliative care. But I'm going to be honest, for that we have a very large team, some remarkable colleagues I've worked with over the years, sub-Saharan Africa, the Middle East, and increasingly, there's a lot of leadership coming out from these countries taking these sorts of programs forward. It's an important time, and I think Ukraine has taught us as well that if you don't think about, for example, cancer care within humanitarian operations, within UNHCR, you can end up in serious trouble in terms of planning, financing, sustainability. So I think Ukraine is going to be an interesting turning point in generally thinking about cancer care and conflict and humanitarian operations because it's really illuminated to everyone very clearly in Europe and the USA, what cancer and conflict really is, because I think the Middle East has felt a little bit far away, and it's been quite difficult selling all that kind of policy and work. But Ukraine is really having a dramatic impact and I think it's producing a lot of learning points. Dave Johnson: You recently published, along with colleagues, I thought, a very provocative paper in JAMA Open Network about the participation of lower and upper middle-income countries in oncology clinical trials led by high-income countries. You made the point, be sure to correct me if I'm wrong on this, that first of all, Ukraine and Russia are actually two of the top participants in these kinds of trials. Number one. Number two, the question is, is it exploitative of the higher-income countries to be conducting these trials in these two countries and then more particularly, what the recent conflict in Ukraine has done to the participation of patients? And I wonder if you might comment on those points. Richard Sullivan: I’ll maybe talk to the last point first. The conflict has been devastating for recruitment. It's also important to realize a lot of these sorts of clinical trials are funded by industry and they've been the backbone of funding research and also to a greater degree also access to certain types of medicines in these countries. Is it exploitative? I think it's a very hard judgment call to make and I think if you ask my Ukrainian colleagues, the answer is no. We know exactly what we were getting into. When companies work in these places, they pay and they pay properly. The difficulty I think is, generally speaking, there is obviously this discussion now ongoing about neocolonialism and exploitation of low middle-income settings more generally. It's very hard, all the research we've been doing, it's very hard to make generalizations. There is absolutely no doubt. I want to recognize right up front that there has been some appalling exploitation and what I would consider to be colonial cancer research going on over the last 20 years. And it's blindingly obvious when you read papers, when you look at authorship, when you undo this sort of analysis, that there has been a lot of exploitation where high-income countries are parachuted in. Investigators have taken whatever they needed data, samples, interview data, made good careers on the back of it and good research funding, and not really put much back into the ecosystem they've been working with. So that's absolutely clear up front. Then we have this other problem, as well as research funding generally, because if you step back and look at the data, and this is something we've published on, actually, with Julie Gralow, and ASCO, we talk the talk about funding global cancer, that's big, high, powerful, wealthy, high-income countries. But when you actually look at the data and you ask that question, of all the cancer research publications, how many from the USA, the UK, the Frances, the Germany are actually with lower middle-income countries, you barely get above 4%. It doesn't take a rocket scientist to realize we taught the talk here, but we're not walking the walk. The money is not being provided to do genuinely equal collaborative work. We've not built capacity and capability in many countries in terms of clinical research methodologies and strengths. We failed to back up a lot of the rhetoric. We talk about global cancer with actually proper cancer research system strengthening. And I think there's that realization, and there's been that realization over the last five or six years that that's been the case. And when you take countries like India who kind of realized, you know, maybe ten to fifteen years ago this was the case, they've obviously gone themselves and driven their own agenda. So the National Cancer Grid of India, the development of Credo, the methodology workforces led by Dr. C.S. Pramesh from the Tata Memorial Centre, has been absolutely superb work. I mean, it's been amazing. A real master class in national development. But I think we do, as high-income countries have to think, look ourselves in the mirror and ask the question, is this what we mean by global cancer? Are we really putting enough money in? And are our research priorities right? You've heard me argue about this enormous amount, about how much money goes into discovery science and biopharmaceuticals. Where's the money going into implementation science, health services research, soci

Diffuse Large B-Cell Lymphoma or DLBCL is the most common type of lymphoma. Much progress has been made in treatment of the disease lately, particularly with emergence of CAR T-cell therapy, but not all patients are benefiting from it. This episode of Cancer Topics features Drs. Loretta Nastoupil and Chijioke Nze exploring treatment approaches for two cases of refractory DLBCL: a 60-year-old man with no comorbidities (1:30) and a 39-year-old woman with HIV (18:35). The guests also discuss improving patient access to CAR T-cell therapy and managing its toxicities (10:35), as well as emerging therapies for DLBCL (14:30). To learn more about management of refractory DLBCL, check out the ASCO course linked bellow. Guest Disclosures:Loretta Nastoupil, MD: Honoraria – Gilead Sciences, Novartis, Bayer, Janssen Oncology, TG Therapeutics, Bristol-Myers Squibb, ADC Therapeuitcs, Morphosys, Epizyme, Genmab, Takeda, Genentech/Roche; Research Funding – Janssen Biotech, Celgene, Genentech/Roche, Epizyme, Novartis, IgM Biosciences, Caribou Biosciences, Gilead Sciences, Allogene Therapeutics, Takeda Chijioke Nze, MD, MPH: No Relationships to Disclose Resources: ASCO Course: Second-line Therapy for Relapsed/Refractory Diffuse Large B-cell Lymphoma (Free to Full and Allied ASCO Members) ASCO Podcast: Cancer Topics - New Therapies for Lymphoma (Part 1) ASCO Guideline: Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor (CAR) T-Cell Therapy ASCO Article: Navigating the Evolving Treatment Landscape of Diffuse Large B-Cell Lymphoma If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org.  TRANSCRIPT The disclosures for guests on this podcast can be found in the show notes. Dr. Loretta Nastoupil: So, I do have optimism that as we have more and more treatment options entering into the treatment landscape, we'll have fewer patients that are experiencing a refractory disease, and potentially succumbing to the lymphoma. Hello, my name is Dr. Loretta Nastoupil, I'm an Associate Professor and Deputy Chair of the Department of Lymphoma and Myeloma, at the University of Texas MD Anderson Cancer Center. Welcome to this ASCO Education podcast episode. It's my pleasure to welcome Dr. Chijioke Nze. Dr. Chijioke Nze: Hello, everyone. I'm Dr. Chijioke Nze, a Hematology/Oncology fellow at MD Anderson, I'll be co-hosting this episode with Dr. Nastoupil. Dr. Loretta Nastoupil: We've seen notable advances in diffuse large B-cell lymphoma research lately, with novel treatments including CAR T-cell therapy, offering the prospect of long-term remission for some patients, yet many patients are not even receiving second-line or later therapy, and even fewer are treated beyond the second line. How do you approach a patient with refractory diffuse large B-cell lymphoma? In today's episode, we'll explore strategies for management of refractory diffuse large B-cell lymphoma through two patient cases. So, Dr. Nze, walk us through our first case. Dr. Chijioke Nze: Our first case is Frank. Frank is 60 years old and has no comorbidities. He presented with severe back pain in September 2021, and was evaluated locally. He had a CT scan that showed retroperitoneal mass, prompting further evaluation. He had a biopsy of the left retroperitoneal mass in November 2021, which was consistent with diffuse large B-cell, germinal center B-cell of phenotype Ki-67 of 90%. He had a subsequent PET-CT scan, which showed a large conglomerate, and invasive left retroperitoneal hypermetabolic mass with satellite nodularity and contiguous bulky retroperitoneal adenopathy. He had bulky, FDG-avid metastatic retrocrural and intrathoracic adenopathy as well. He was treated with R-CHOP for six cycles, and at the end, achieved complete remission. He had a PET-CT a year later that showed new and worsening intensely FDG-avid abdominal adenopathy. This was new from a PET scan he'd had in January 2022 of the same year. He had a biopsy of this retroperitoneal adenopathy, which was consistent with relapsed diffuse large B-cell germinal center phenotype, also Ki-67 of 90%. Locally, he was treated with ICE, times five cycles, and had a follow-up CT scan at the end, which showed persistent bulky nodal disease with periaortic regional nodes with double 5, consistent with persistent disease. He also was found to have new and more conspicuous nodes in other areas as well. He presented for his first visit at MD Anderson in September 2022. Dr. Nastoupil, when you see a patient like this coming into your clinic, what's your typical approach? Dr. Loretta Nastoupil: For a diffuse large B-cell lymphoma, we are always hoping for cure with frontline rituximab, containing anthracycline-based chemotherapy. And so, it's always a gross disappointment when patients experience relapse. The timing of that relapse right now informs our current approach. And the reason I mention that, is because there have been three large randomized studies conducted and reported out just in the last year demonstrating that CAR T-cell therapy is the preferred option for patients who experience either primary refractory disease, or relapse within 12 months. And that is because they resulted in better outcomes than standard salvage-based chemotherapy and high-dose therapy autotransplant in the setting of chemosensitive disease. I have to acknowledge, of the three studies that were done, two were positive trials, so that's why currently, we have axi-cel or Axicabtagene ciloleucel, or Lisocabtagene maraleucel, and not tisa-cel or Tisagenlecleucel, as CAR T-cell therapy options. And again, that's because two of the three studies were positive trials. Now, the challenge is why would we have two positive studies in one negative trial? There are a lot of caveats to how those studies were conducted, but I think one of the biggest important lessons to be gained is that if you're going to consider CAR T for these high-risk patients, you want to do it as soon as possible, because that delay from identifying CAR T as a preferred option to actually infusing cells in a disease-- in a case particularly like this, where patients may have bulky, aggressively-behaving disease - that prolonged time may actually have an impact on outcomes. Dr. Chijioke Nze: Excellent. Thank you. So, you've mentioned he had an early relapse. How would you define early relapse in this patient population? Dr. Loretta Nastoupil: Thinking back to how we've been approaching diffuse large B-cell lymphoma over the last two decades, the PARMA study, which was done prior to Rituximab, suggested that for patients who had chemosensitive disease to a platinum-based salvage chemotherapy, which generally, was at least a partial response on CT, if they went on to high-dose therapy autologous stem cell transplant, 50-60% of those patients could anticipate cure. Whereas for the folks who continued on salvage chemotherapy, 10-20% of those patients had favorable outcome. So, we generally do try salvage-based chemotherapy, and for patients with chemosensitive disease, go on to high-dose therapy autotransplant. However, in the modern era where we've approached patients who've had rituximab as part of their frontline therapy, at least two studies - the ORCHARD study, and the CORAL study suggested that only 20% of patients who relapse in the post-rituximab era, particularly within 12 months, were successfully salvaged with platinum-based chemotherapy and high-dose therapy autologous stem cell transplant. Now, fortunately for patients who fail salvage, we have had CAR T-cell therapy as an option based off of three pivotal phase II studies, demonstrating about 40% of patients could anticipate a cure with CAR T-cell therapy. So, it only made sense to try and move that therapy up into second line, and the preferred population was those that had progressed within 12 months of frontline rituximab and anthracycline-based chemo. Now, to qualify for those studies, patients had to be considered fit for the control arm, which was salvage and auto transplant. Nonetheless, I do think for a patient like this, who's 60, without any other significant comorbidities, whose biggest challenge to longevity of life is his aggressive lymphoma, CAR T-cell therapy should be considered as soon as possible for this patient. Dr. Chijioke Nze: Is there still a role for high-dose therapy and autologous transplant in the new era, given the efficacy shown with CAR T-cell therapy? Dr. Loretta Nastoupil: I think there is. And the reason why I say that is, the trials that were done really did focus on the highest-risk patients, which were those with primary refractory disease or those who progress within 12 months of frontline. Now, there are patients that will have later relapse. And so, I do think for those patients, particularly those who are young and otherwise fit, should be approached first with a platinum-based salvage chemotherapy, in the setting of chemosensitive disease, proceed onto high-dose therapy and autologous stem cell transplant. Now, what do we do for those patients who have a late relapse but are otherwise older, or who have comorbidities that would make them suboptimal candidates for the high-dose therapy preceding stem cell transplant? I have a couple other options for those patients - so, there was a trial done with liso-cel for patients who were otherwise older, or not fit for intensive therapy. It's a single-arm phase II without a randomized comparison, but also demonstrated that liso-cel in second-line, later relapsed patients who are not fit for intensive therapy, resulted in comparable outcomes to what we would anticipate on that third-line or later setting. We also have other non-CAR T-cell therapy options, such as tafasitamab, which is a naked CD19 antibody, which has been combined with lenalidomide in the L-MIND study, again, for patients withou