Cancer.Net Podcast

 [music] ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. Greg Guthrie: Hi everyone, I'm Greg Guthrie, a member of ASCO's patient education content team, and I'll be your host for today's podcast. ASCO is the American Society of Clinical Oncology, and we're the world's leading professional organization for physicians and oncology professionals caring for people with cancer. Today we're going to be talking about what patients should know about cannabis, cannabinoids, and cancer. ASCO recently published a clinical practice guideline on cannabis and cannabinoids for adults with cancer. I'm happy to have 2 of the co-chairs from the committee that developed this guideline as our guests today. Dr. Ilana Braun is an associate professor at Harvard Medical School. Thanks for joining us, Dr. Braun. Dr. Ilana Braun: Thanks so much for having me. Greg Guthrie: It's a pleasure to have you here today. And Dr. Eric Roeland is an associate professor of medicine at Oregon Health and Science University. Welcome Dr. Roeland. Dr. Eric Roeland: Thanks, Greg. Greg Guthrie Great. So before we begin, I want to note that neither Dr. Braun nor Dr. Roeland have any relationships to disclose related to this podcast, but you can find their full disclosures in this podcast's show notes. So let's start with the fundamental question about this discussion, and that is what is a clinical practice guideline and how does it help guide cancer care? Dr. Roeland, can you start with this? Dr. Eric Roeland: Of course, yeah. A clinical practice guideline describes the best practices or what clinicians call the “standard of care” with regard to a specific topic. So this is kind of the blueprint that clinicians use to guide their practice when taking care of people with cancer. And the American Society of Clinical Oncology clinical practice guideline on the use of cannabis and/or cannabinoids summarizes the best available data collected specifically from humans in clinical trials, and we combined that with a multi-disciplinary panel of expert opinion. Greg Guthrie: Yeah, I think it's really important to always remember that best evidence comes from research in humans as well as from clinical expertise. So it's the best recommendations that we can have to support cancer care.   Dr. Eric Roeland: Greg, I also think it's very important to understand that there are different places that we gain knowledge in research. One is specifically when we are trying to figure out how a drug works, and we will test that in what we call “preclinical models,” which is usually within animals. And then, once we’ve determined safety and efficacy, then we start taking that information and approach studies in humans. And so when our listeners are learning about new data in the use of cannabis or cannabinoids, I encourage everyone to always stop and ask, is this data coming from the animals or is this from humans? Greg Guthrie: That's such an important point. And I think it's so essential to always look for that piece of evidence whenever you're reading about scientific advances. Alright, so let's take a moment to talk about what it means when we say cannabis and cannabinoids. Dr. Braun? Dr. Ilana Braun: Cannabis, which is better known as marijuana, is a plant that humans have turned to for thousands of years as a medicine, in manufacturing—for instance, in the making of rope­—and for enjoyment. It's often mistakenly viewed as having one main ingredient, tetrahydrocannabinol, or THC, but it actually has more than 300 ingredients that act in the body. Some of those ingredients are referred to as cannabinoids. There are 2 cannabinoids of greatest interest, THC, which I just mentioned, and CBD, cannabidiol. THC is responsible for the high feeling some people experience with cannabis. CBD is not. Currently in the U.S., some cannabis products containing these cannabinoids can be sourced at the pharmacy, others at cannabis dispensaries, and some through more informal means. Greg Guthrie: That's great. Thank you for that definition here as we continue this discussion. So what do people with cancer typically think cannabis and cannabinoids will do to help them? Dr. Roeland? Dr. Eric Roeland: Well, it's a great question, Greg, because in clinic, when patients and their loved ones express interest in either starting cannabis or cannabinoids or are currently using them, I always want to explore what their goal of use is. And interestingly, the goals of use are far-reaching. And I have heard everything from, to help with everything, to cure my cancer. And so it's incredibly important to understand why people are reaching towards these products, to understand what their goals are. If they're focused on using this to treat the underlying cancer, or instead of standard cancer therapies, we have grave concerns about this approach. And it may lead to worse outcomes of your cancer. However, if cannabis or cannabinoids are being used to help with controlling some symptoms during their cancer treatment, it may be helpful. And especially in one particular case where people have really bad nausea and vomiting that persists despite our best medicines to prevent it. Greg Guthrie: Thank you for that, Dr. Roeland. Dr. Braun, did you have anything to add? Dr. Ilana Braun: Maybe I will just point out that decisions on what to target with cannabis are often made through trial and error or in consultation with dispensaries, but not as much as I would prefer in consultation with clinical teams. Dr. Eric Roeland: So I would also add that it's incredibly important to bring these topics up with your clinical team because although cannabis and cannabinoids are considered safe by many because they're quote “natural,” it's important to recognize that they actually can interact with many of the other medications that you're already taking. For example, patients with cancer might be experiencing really bad pain or anxiety and taking things like opioids or benzodiazepines. And when you combine that with cannabis, it can prolong some of the effects of sedation or confusion. I'd also like to point out that this is not a time where people want to try cannabis for the first time, when they are weak and/or experiencing poor appetite and higher risk of falls. This is not the best time to be trying cannabis or cannabinoids without clear guidance from the clinical care team. Greg Guthrie: Do you find in writing this guideline and through your clinical experience that most people who are asking about cannabis and cannabinoids, that they already have been trying to use it or are considering it? Because there's a difference there, right? What goal are they looking for, and do they already have a predetermined assumption about what's going to happen with these? Dr. Eric Roeland: You know, Greg, as clinicians, we talk about a lot of hard stuff. We talk about challenges in terms of health care, access to care, cultural differences, financial toxicity. And it's so fascinating to me that we don't talk about something as simple as whether or not patients are using cannabis. And the reality is that when patients actually bring it up in clinic, I would say that most times they're already using it and are just simply asking for some advice on how to use it safely and effectively. So once I decided to lean in on this topic and create a space for patients and their loved ones to bring it up in clinic, I have found that it's brought up during most clinical encounters. Greg Guthrie: Fascinating. And so that's likely why the first recommendation of this guideline addresses the importance of communication between doctors and patients on this topic, correct? Dr. Eric Roeland: Yes, absolutely. I think that doctors are reticent to talk about this topic because of concerns around legal issues, which can be highly varied across the country. And Dr. Braun can speak to this more. Dr. Ilana Braun: Yeah, so in order to offer the very best care possible, I think that medical teams should know about all the medicines and supplements a person is taking. And this includes cannabis and cannabinoid products. Why? Well, because, as Dr. Roeland mentioned, cannabis and cannabinoids can sometimes decrease the effectiveness of some therapies that a person is on, likely including some cancer treatments, and they can also worsen side effects of other therapies. And then at the same time, cannabis and cannabinoids can be helpful in managing some symptoms of cancer and side effects of cancer treatment. So using them involves a careful weighing of risks and benefits. So for these reasons, oncology teams really do want to be part of the conversation as someone thinks through decisions around cannabis and cannabinoids. The ASCO guidelines encourage clinicians to be open and non-judgmental and welcome transparent discussions with patients about cannabis and cannabinoids. From there, clinicians should either assist personally if they feel qualified to do so, or refer a patient to high-quality information or an advisor with greater expertise. As for the types of information that might be helpful to share with the clinical team, a person with cancer who consumes cannabis or cannabinoids might wish to share why they're turning to cannabis, where th

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this Meaningful Conversations podcast, Dr. Karan Jatwani talks to Dr. Amy Case about what people with cancer should know about hospice care, including the difference between palliative and supportive care and hospice care, who is eligible to enroll in hospice care, and the types of support available for people receiving hospice care and their family and caregivers. Meaningful Conversations is a Cancer.Net blog and podcast series that describes the important discussions people may need to have with their providers, caregivers, and loved ones during cancer and offers ways to help navigate these conversations. Dr. Jatwani is a Medical Oncology Fellow at Roswell Park Comprehensive Cancer Center. Dr. Case is the Lee Foundation Endowed Chair of the Department of Palliative and Supportive Care at Roswell Park Comprehensive Cancer Center, and Professor of Medicine at the Jacobs School of Medicine and Biomedical Sciences of the University at Buffalo. View disclosures for Dr. Jatwani and Dr. Case at Cancer.Net. Dr. Jatwani: Hi, everyone. My name is Karan Jatwani. I'm one of the 3-year fellows at Roswell Park Comprehensive Cancer Center. I have finished my palliative care fellowship from Memorial Sloan Kettering Cancer Center. And I am interested in the integration of oncology as well as palliative care, and that is where I envision my future career to be. And it's my pleasure to be involved in a podcast with Cancer.Net and looking forward to it. Dr. Case: Hello. My name is Amy Case, and I'm the chair of the Department of Supportive and Palliative Care here at Roswell Park Comprehensive Cancer Center, and we're in Buffalo, New York. So I appreciate being invited to speak today. And we also have a fellowship that we run here and a pretty comprehensive department with 8 divisions that include palliative, social work, psychiatry, psychology, spiritual care, bioethics, and geriatrics, and also employee resilience. So we have a lot of kind of passion projects we work on in our supportive care department. Dr. Jatwani: Thank you so much, Dr. Case, for joining us today. I think I've always admired your work. And just to start off, just for our listeners and our audience, if you can just give us a brief idea of what palliative care is, I think that would be the best segue to enhance the discussion. Dr. Jatwani: So “to palliate” means to make feel better. And when I talk to patients about what it is that we do, I talk about how we take care of the whole person, which includes the physical symptom management, the emotional support, which could include psychiatry, psychology, or social work support of the emotional piece. And then also the spiritual support, which often we work as a team. In order to be palliative care, you actually need to be a team. It can't just be one physician, for example, doing palliative. You need to work as a team. So generally, a core team consists of a physician, a nurse, a chaplain, a spiritual care professional, and a social worker at its core. But sometimes it can be a nurse practitioner providing that or other specialists helping on that team. Dr. Jatwani: I think one of the key questions that always arise with the patients is, as soon as you talk about palliative care, patients start equating it to death. How do you make sure that the patients you're interacting with, how do you differentiate it with them, and how do you relieve that anxiety whenever the patient hears “palliative care”? Dr. Case: So no matter what you call the work that we do, there will always be a stigma. So if we change the name to yellow banana, people would be afraid of yellow bananas, right? So I think that the word hospice has-- I joke that it's kind of like a 4-letter word type of situation. We call it “the H word.” Sometimes patients are really fearful to hear that word. And even now, palliative has adopted this stigma. So generally, what I do is I kind of say that it's focused on quality of life. The main goal is to help people feel better, live a better quality of life, to get through their cancer treatments. And I also educate them that people who receive palliative care tend to have better outcomes. Patient-reported outcome metrics are better. So patients often have a prolonged survival. They may be able to tolerate their cancer treatment better and get through those treatments. And that generally, I would say, is something that they're happy to hear. That's something that they're usually, "Yeah, sign me up for that." When we start with somebody-- we spend an hour with every patient for a new visit. When I start with them, they're really skeptical. Oftentimes, they're looking at me mistrustfully, like, "What is this?" And by the end of the visit, they say, "Where has this been from the beginning of my cancer journey? And why am I only getting this now? This was the best interaction I've had at this organization." And it's because we give them kind of what we call a “wrap-around care,” which is almost like a big hug. We use a lot of skills that include empathy. And with our communication, we often spend a lot of time listening. And I think people really walk out feeling heard. Even if you can't solve it or cure it, you can discuss things that can just make them feel that you were there for them and you listened. And that is very powerful. Dr. Jatwani: I 100% agree. I mean, that has been my sort of experience as well during my fellowship. I took a lot of those learnings with me when I see my patients. But also, I think coming from an oncology standpoint, I can definitely now understand that I have been at fault when I have not given that palliative blanket that you were talking about at different times. And so my question is, when can patients ask for palliative care? And we'll discuss “the H word,” as you mentioned at the beginning. So we'll discuss with that as well. But when should patients undergoing cancer treatment, when should they ask for involvement of palliative care, or they should advocate for themselves or even the caregivers should advocate? Dr. Case: Yeah. So I think that generally, palliative care, the beauty of palliative care is that it doesn't really have a time limit. Someone can ask for it anytime. And often, we encourage people right from the beginning. So there's people who may be looking for that extra added support right from the beginning. And so we usually encourage oncologists and the oncology teams to start those discussions themselves. Dr. Jatwani: And I think at this point of time, I would like to definitely ask you. I think you mentioned “the H word” in the beginning. So can we discuss a little bit more about what is hospice care? Dr. Case: So palliative care is provided on a trajectory. So it can be provided anytime, even for survivors, for people who are earlier in their diagnosis. But hospice has a timeline on it because it's actually a Medicare benefit that it's like almost like an insurance benefit that kicks in, but the government pays for the patient's care. And so in order to enroll or sign up for hospice, a patient has to have certain criteria in order to meet that. In order to get those things paid for. And so hospices have to—generally, it's when a patient has a life expectancy of 6 months or less, and they have decided that the cancer treatment, meaning chemotherapy, radiation in most cases, immunotherapy, the burden of that is higher than the benefit. Most of the patients who see us in palliative are still getting their cancer treatment, and we're helping them walk the journey with them through their treatment, helping them feel better, starting those conversations. And then we do something called a transition to hospice. So many of the patients we see in palliative end up transitioning to hospice. How is palliative care different than hospice? How is hospice different than palliative care? They're very similar. The philosophy of care and the way it's provided is almost exact, meaning that it's a team-based approach made up of physical, emotional, and spiritual support for the patient provided by a team. Although in palliative care, many times that's done in a clinic or an inpatient setting. There are home palliative programs that exist. We have one here at Roswell as well. But hospice, 80% of the time, is done at home. Because generally, when people prefer to pass away and we talk to them, where do they want to be at the end of their life? I'd say 95% of people do want to be at home if that's feasible. The biggest barrier that they are worried about dying at home is that they worry about being a burden on their loved ones. And so that's the way I frame those discussions, is that I ask them about what are the things that they're hoping for. What are the things that they're worried about? And when I find out, inevitably, like I said, it's probably the number 1 fear of people to be a burden on their loved ones. It's this wonderful thing that can reduce burden on family to help care for you and have you be at peace in the place that you wish to be. Dr. Jatwani: I 100% agree. I think you framed it perfectly that if the discussions-- I think, as you said, they should happen at the right time point. And the o

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this podcast, the Reverend Jane Jeuland discusses what people with cancer should know about the role of chaplains in cancer care, including how chaplains are trained, the type of support they can provide for people with cancer and their family members and caregivers, and how someone with cancer can ask for spiritual support from their health care team. Ms. Jeuland received her Masters of Divinity from Yale Divinity School. She is an ordained Episcopal priest. She received her chaplaincy training from Yale New Haven Hospital and is a board-certified chaplain. She has served as an oncology chaplain and was the first palliative care chaplain at Yale New Haven Hospital. She has no relevant relationships to disclose.  Jane Jeuland: Hi, my name is Jane Jeuland, and I am the palliative care clinic chaplain at Yale New Haven Hospital. I'm here today to talk a little bit about what I do at Yale New Haven Hospital, and also, what is a chaplain? What is it that we offer and provide? How are we trained? And some other questions that people have for us as chaplains. So I'll start by just describing a little bit about what I do at Yale New Haven Hospital in my role. In addition to seeing patients in our clinic, I visit with patients one-on-one through video platforms, phone, and I also visit with patients in person for scheduled appointments. And in those appointments, we get to know each other, we build a rapport and a relationship. And I help people process how they make meaning, find purpose and belonging in their lives, and how that is impacting their cancer care, but also how their cancer is really impacting their meaning, purpose, and belonging. In addition to those individual meetings, I also visit with patients in group settings. I host several groups over Zoom where patients get to talk to one another and share deeply and support each other. And last but certainly not least, I also have started a podcast with my patients called In the Midst of It All, which you can find on Apple Podcasts and Spotify. And in that podcast, patients share their stories that they've written about their lives, about their cancer journey, and about their spirituality, and how that has helped them through all that they're going through. So, how do chaplains get trained? I think this is one thing that people ask me quite a bit. What is your training like? Our training is pretty extensive. We need to have a 3-year Master's degree, typically a degree of divinity. And then after that, we have a year of training called Clinical Pastoral Education, CPE for short. And in that year of training, we are with a cohort of about 4 to 5 other chaplains in training. And we are supervised by a highly trained supervisor as well who has quite an extensive and long process to get certified to do that. And what our supervisors do is they help us really go out, visit with patients, and then reflect on those visits. We do things called “verbatims.” So what is a verbatim? When we write up a verbatim, we're writing up word for word an interaction that we have with a patient. And obviously, we will keep the patient confidential. But we do this with our group and with our supervisor to really kind of drill down and see where are the places that we are inserting ourselves, our own beliefs, our own needs, and how can we really better meet the patient where they are? We talk a lot about positive use of self so that we become really aware of our own self in the midst of our interaction with patients. And over the course of the year, we really learn how to focus on the patient's spirituality, their beliefs, their values, what they need in that moment. And we're all about helping people discover their spirituality and their faith. I think sometimes a lot of people think that we might be coming in to convert someone or to make them believe a certain belief system or a certain religion. But actually, we're really here to help any patient and caregiver really figure out what it is that they believe, and how that's impacting their cancer care or how their cancer is impacting their beliefs. So that means that we do visit with people of all different faiths. We visit with people who are atheists and agnostic as well. And really, again, just try to help people discover, what is that value that you have? What are your beliefs? Where do you find meaning, purpose, and belonging? And so what are some things that come up as we meet with patients? I, again, work in palliative care in the clinic settings. I'm outpatient. But a lot of chaplains work inpatient in a variety of settings. And so you'll have chaplains in a medical intensive care unit (ICU), or you'll have a chaplain in an infusion suite or on a floor as well. And so we see patients at all different stages. We see patients who are just newly diagnosed and have a cancer that's highly treatable. We see patients who are doing really, really well on their treatments. And we also see patients who are starting to kind of struggle with lots of symptoms, pain through sometimes months or years of cancer treatments. And then on the other end of this spectrum, we see patients who are very advanced in their cancer, have a terminal diagnosis, and we really see them through all that that entails, the outpatient visits as well as the inpatient, and even as someone comes to the end of their lives. And so what can come up in our meetings as I meet with patients? When someone's diagnosed with a terminal diagnosis, there is a lot of discussion about fear of dying, what happens in the process of dying, and then also, of course, what happens after we die? What is there after we die? Is there anything after we die? Or what is the afterlife like? And so often, again, I try to help people really reflect on what they may think the afterlife is like, if there is one. And then we have rich discussions around that. For kind of that big question of what happens as we're dying, that's when I like to pull in other members of the team. But certainly, chaplains can help process that as well. We also really do help people articulate their thoughts about the divine and whatever name they give to the divine. And often, what I hear in my appointments is not so much, “Is the divine as God giving me this cancer?” but, “Why would God allow it?” So as I talk with folks, folks will say, "I really believe in a loving God and a God that heals and a God that helps us. Why would a God like that allow me to have this cancer? Why would God allow my loved one to have this cancer and for their lives to be taken far, far too soon?" And for that, it's a tricky one. We, as chaplains, don't have a pill that we can give you and send you home and say, "OK, here's your prescription. Take that, and you'll get all the answers to why would God allow this?" So it's really a process of talking through this. It's a process of kind of discovering a little bit more about what we believe God is, what the patient believes about God, and God's character in the midst of it all. And it's also just sitting in the mystery of it that we don't know. We don't know why a loving God would allow this, why a God that heals would heal some people and not others, why a God who heals would heal at this point in your life, and then not at a different point in your life, and why this happens at all. And so chaplains don't rush quick to give advice. We allow sitting in that grief, in that suffering, in the sorrow. But then again, as we talk about who is God for this person, I also like to help people see, OK, if God isn't healing right now, if we can't understand why God is allowing this to happen, where is God in the midst of it? And this is what I love about my job so much is that I hear from such a variety of faiths and people of different values and spiritualities, how they do see the divine working in their lives. And so for some, "I have a lot of pain, but I know that God is with me, and I don't feel alone in this." Or, "I was feeling grief and loss over a loved one and wondering what my afterlife's going to be like as I face the end of my life and I was having this turmoil. And all of a sudden, I felt this deep, deep, deep peace wash over me. And I feel like that might be God." Or for someone who maybe doesn't have a particular religion, they may say, "I know that the love of my family and friends is so powerful. It's helping me through this. It's getting me through the dark times. And I know that that is what holds us together. And it's more than just what we can see and taste and feel, that that love is something greater and bigger." So it's really rich conversations like that that I get to have. I think also some other topics that come up is cancer is grueling. Cancer, it can be long. And there are things, people talk about scan anxiety. Of course, the side effects and physical pain. I hear a lot about insurance and how that's just so difficult and such a struggle to get on the phone, talk about insurance when time is so precious and so short. And for others who are healing from cancer, it sometimes is a lot of conversation about, "Well, how do I get back to life? And I used to do this amazing job, but I don't think that

ASCO: You’re listening to a podcast from Cancer.Net (Cancer dot Net). This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this podcast, Dr. Fay Hlubocky  and Shelly Rosenfeld discuss what people should know about returning to work after cancer treatment. This podcast is intended for informational purposes only and does not constitute legal or medical advice.  Dr. Hlubocky is a licensed clinical health psychologist with an expertise in psychosocial oncology and a health care ethicist at the University of Chicago. She's also the Cancer.Net Associate Editor for Psychosocial Oncology. Ms. Rosenfeld is the director of the Disability Rights Legal Center’s Cancer Legal Resource Center, which provides free information and resources about cancer-related issues.  View disclosures for Dr. Hlubocky and Ms. Rosenfeld at Cancer.Net. Claire Smith: Hi, everyone. I'm Claire Smith, a member of the Cancer.Net team, and I'll be your host for today's Cancer.Net podcast. Cancer.Net is the patient education website of ASCO, the American Society of Clinical Oncology. Today, we'll be talking about what people with cancer should know about returning to work after treatment, including information about the legal protections available to people with cancer in the United States. Our guests today are Dr. Fay Hlubocky and Ms. Shelly Rosenfeld. Dr. Hlubocky is a licensed clinical health psychologist with an expertise in psychosocial oncology and a health care ethicist at the University of Chicago. She's also the Cancer.Net Associate Editor for Psychosocial Oncology. Thanks for joining us today, Dr. Hlubocky. Dr. Fay Hlubocky: Thank you, Claire. It's such an honor and a privilege to be with you and Shelly today. Claire Smith: Wonderful. Our next guest, Ms. Rosenfeld, is the director of Disability Rights Legal Center's Cancer Legal Resource Center, which provides free information and resources about cancer-related legal issues to members of the cancer community across the U.S. Thanks so much for being here, Ms. Rosenfeld. Shelly Rosenfeld: Thank you. I'm honored and grateful to be here today. Claire Smith: Before we begin, I should mention that Dr. Hlubocky and Ms. Rosenfeld do not have any relationships to disclose related to this podcast, and you can find their full disclosures on Cancer.Net. So, to start, Dr. Hlubocky, can you talk a little bit about some of the ways that people might think about work differently after an experience like cancer? Dr. Fay Hlubocky: Thank you, Claire. That's such an important question to start today's talk with. For many, the thoughts and decision-making surrounding returning to work can be very complex. Perspectives on if, how, and when to return to work will differ from person to person. Although one may feel quite motivated and even inspired to return to work after the cancer experience, the idea to return to work immediately after this post-cancer journey phase may simply seem overwhelming and bring about anxious and worrying thoughts. Thoughts and questions such as, "Am I ready to return to work after all I've been through?" or "Can I do the job like I did before?" are common and expected. For some who may experience financial burdens, these individuals feel compelled to return to work with thoughts of, "I have to get back to work," and feel like that's the only option is to return to work immediately even if not ready. Yet others may ask themselves, "Should I work full- or part-time? How can I return to work?" Or, "Can I return to that same busy schedule as I had engaged in before?" Finally, some may wonder if that same job is right for them after all one has been through. Again, these are very normal, common, and expected thoughts and questions regarding return to work that the individuals certainly may hold after the cancer experience. Claire Smith: Wonderful. Thank you for that overview. And next, you touched on some concerns, but I'd love to hear about what concerns someone might have about returning to work after cancer. Let's go to you, Ms. Rosenfeld. Shelly Rosenfeld: Well, one concern for someone returning to work, it could be either, of course, returning to their job, but it can also be returning to work and starting a new job. And that might be when one might need to perhaps take additional days off, and whether it's for treatment or follow-up care or perhaps just monitoring as well. But to use up those sick days and then to need additional sick days, there is protections out there such as Family and Medical Leave Act, or FMLA. But a concern for someone starting a new job is, in order to be covered by FMLA or the Family and Medical Leave Act, someone has to have worked for the employer for a total of 12 months and have worked at least 1,250 hours in the last 12 months, which comes out to a little more than part-time. But that is certainly a concern because taking time off whether to care-- actually, it could also be a caregiver taking care of someone with cancer, that they need to have worked for that employer for at least 12 months. Later, I think we might be talking about one way to work with the employer in terms of - just to kind of hint with the Americans with Disabilities Act - kind of a creative way to ask for additional time off and to see if that can work out with the employer. So I want to wait until we talk about that a little more in depth, but I just want to say there is hope and there is something that perhaps can be worked out with your employer if there is that concern. But I just want to say that while FMLA, and just to kind of briefly touch upon it, it allows certain employees to take up to 12 work weeks per year to take care of oneself or certain family members with a serious health condition. For example, that could include a spouse, parent, or child. So it is unpaid, but one's job has to stay open for that person until the end of that 12-week period, and the employer has to keep providing health benefits. So it's something to keep in mind if somebody is returning to work and is at their job now for some time and needs to take those days off. Beyond those sick days, there are protections out there. But if they're just returning to work and they haven't been at a job for that long, then they should consider, "OK. Maybe the state has additional protections that the federal law does not have," or to think about-- and we'll talk about reasonable accommodations in Americans with Disabilities Act in a bit, I think, as a solution. So with every challenge, I think there is some kind of option, but that is certainly a concern. Claire Smith: Yeah. Absolutely. I think it's so important to sort of think about these concerns as people are going to worry about them, but there are ways to sort of address and hopefully cope with them. Dr. Hlubocky, do you have anything else to add? Dr. Fay Hlubocky: I agree, many survivors we know with cancer do desire to return to work. Just recognizing the fact that holding a job provides a routine, a schedule, freedom, income, meaning, it makes us feel fulfilled, it gives us a sense of purpose, and work specifically for survivors can bring a sense of normality, especially after that cancer experience. Yet for others, we know that the thought of returning to work can be very concerning. Folks might be worried over their energy and their endurance and ability to really perform at their job due to continuing or existing cancer-related or treatment-related symptoms, such as fatigue or insomnia or pain. Others may worry about colleagues' attitudes and relationships, concerns and fears over if colleagues will judge them for their appearance or their performance may arise. As well, many survivors question, “How will I be treated?” or “Will they work with me as they did before?” These are also frequent and commonly held concerns by many patients and survivors. For all survivors, it's important to recognize that this is a new normal, a new phase in this journey post-cancer and cancer treatment that can really bring a new perspective with greater meaning and purpose. This new perspective - really, this growth - can be a motivator and inspire not only you in the work environment but your colleagues as well. Claire Smith: So talking about maybe some of the things that we can share with our listeners to help assuage some of these concerns that they may have. I want to start, if someone is applying for a new job after cancer treatment, maybe they've been out of the workforce for a little while while going through cancer and its treatment, are there any legal protections available to them during that process, Ms. Rosenfeld? Shelly Rosenfeld: There are. So I briefly mentioned the Americans with Disabilities Act, or ADA, which is a federal law that makes it illegal for employers with 15 or more employees to discriminate against, and it includes qualified job applicants or qualified employees with disabilities in any stage of the employment process. So that includes the interview process. A lot of people don't know that before someone even starts working, that they do have those protections. So that is really important for someone to keep in mind as they go through the interview process. So an employer is not allowed to ask about a job applicant's medical history, whether they've taken any leave i

You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this podcast, members of the Cancer.Net Editorial Board discuss the latest research, innovations, and discussions taking place across the field of genitourinary cancers, including prostate cancer, bladder cancer, kidney cancer, and testicular cancer. This podcast is led by Cancer.Net Associate Editor for Genitourinary Cancers, Dr. Petros Grivas. Dr. Grivas is the clinical director of the Genitourinary Cancers Program at University of Washington Medicine and a professor in the clinical research division at the Fred Hutchinson Cancer Research Center. He is joined by Dr. Neeraj Agarwal, Dr. Shilpa Gupta, Dr. Tian Zhang, and Dr. Timothy Gilligan. Dr. Agarwal is a Professor of Medicine, and a Presidential Endowed Chair of Cancer Research at the Huntsman Cancer Institute at the University of Utah. He directs the Genitourinary Oncology Program and Center of Investigational Therapeutics at the Huntsman Cancer Institute. He is also the Cancer.Net Specialty Editor for Prostate Cancer. Dr. Gupta is the Director of the Genitourinary Medical Oncology Program at Taussig Cancer Institute and Co-Leader of the Genitourinary Oncology Program at Cleveland Clinic. She is also the Cancer.Net Specialty Editor for Bladder Cancer. Dr. Zhang is an Associate Professor of Internal Medicine at UT Southwestern Medical Center and a medical oncologist at the Harold C. Simmons Comprehensive Cancer Center. She is also the Cancer.Net Specialty Editor for Kidney Cancer. Dr. Gilligan is a Medical Oncologist, Associate Professor of Medicine, and Vice-Chair for Education at the Cleveland Clinic Taussig Cancer Institute. He is also the Cancer.Net Specialty Editor for Testicular Cancer.  View full disclosures for Dr. Grivas, Dr. Agarwal, Dr. Gupta, Dr. Zhang, and Dr. Gilligan at Cancer.Net. Dr. Grivas: Hello. I'm Dr. Petros Grivas. I'm a medical oncologist in Seattle, a professor at the University of Washington and Fred Hutchinson Cancer Center. I'm really excited and thrilled today to host wonderful superstars in the field of GU Medical Oncology who will share insights about the highlights of kidney cancer, prostate cancer, and bladder, urothelial, urinary tract cancers that happened in 2023. And this highlight aims to inform our great audience about what are the clinically relevant insights, what patients should be aware, what patients should ask for when they go to the clinic, or overall, how they can be most well-informed and have the necessary tools to improve their care and feel well-supported in regards to education. So without further ado, we're going to cover in first prostate cancer, a very important update in this year. So all the people out there that are interested in hearing about prostate cancer will find this very, very useful and insightful. I'm very excited to host Professor, Dr. Neeraj Agarwal from University of Utah. Neeraj, do you want to introduce yourself? Dr. Agarwal: Of course. It's such an honor to be here. My name is Dr. Neeraj Agarwal. I'm a professor of medicine and director of genitourinary oncology program at the University of Utah Huntsman Cancer Institute. Dr. Grivas: Neeraj, thank you so much for accepting the invitation and being with us. I would like to ask you, what's your take on the current state of genetic testing in patients with prostate cancer? And when we say genetic testing, maybe you can clarify the distinction between germline and somatic and comment on both if you could. Thank you. Dr. Agarwal: Of course, a very important topic. I must tell you that it is very clear from all the guidelines that in patients with advanced prostate cancer or metastatic prostate cancer, meaning when prostate cancer has spread to different parts of the body, both germline testing to look for hereditary mutations in the DNA repair genes and testing for the same genes inside the tumor tissue are considered standard of care. So, a patient with advanced prostate cancer should have germline testing and somatic tumor tissue testing to look for mutations that can predispose them to have prostate cancer, and if they have genes in the tumor which can be targeted by the current approved drugs, like drugs which are already approved right now or which are in clinical trials. Unfortunately, less than 50% of patients in many areas of the country and in the world, less than 20% of patients are being tested. And even more, unfortunately, patients are less likely to be tested are those who are not well-resourced, who are not living in rich countries, if you will. They are poor- or low-resourced countries. Even with high-income countries, within those countries, patients who are living in relatively not-so-affluent neighborhoods, they are less likely to be tested. From racial perspective, patients who are Black or who are Hispanics are less likely to be tested. Based on how many drugs are out there in the clinic and emerging through clinical trials. And the fact that we can use many of these mutations for prognostication, to inform survival, to inform aggressiveness of the disease. It is not only to treat those patients, but also how to monitor the disease. The genetic testing is very important. Dr. Grivas: Thank you so much, Neeraj. It's very insightful. And I think you did a great job outlining the clinical relevance for both the patient in terms of treatment decision-making and therapy options, especially for advanced prostate cancer, as well as the broader family and implications for cancer prevention and cancer screening for the broader family members. So definitely a very important topic. Neeraj, the other question I have, if you could tell us more about this class of medications called PARP inhibitors. If you can comment on the currently approved PARP inhibitors, either as a single agent, what we call monotherapy or combination therapies for patients with prostate cancer in the United States, and who is eligible to receive those therapies? Dr. Agarwal: And this is such a nice segue to talk about PARP inhibitors as we were just talking about genetic testing of prostate cancer. So, PARP inhibitors are a class of drug which are instrumental, critical in treatment of patients who harbor mutations in those DNA repair genes. And two monotherapies, meaning using these PARP inhibitors as single agents have been already approved in the United States and several other countries. These are olaparib or rucaparib. Olaparib is approved after patients have had disease progression on novel androgen-blocking therapies or androgen blockers such as enzalutamide or abiraterone or apalutamide. And these PARP inhibitors such as olaparib or rucaparib can be used for those patients as single agent if they have these DNA repair mutations. Now, last year, we saw several combinations of PARP inhibitors with these androgen or novel hormonal therapy, as we call them. And these include abiraterone plus olaparib, abiraterone plus niraparib, and talazoparib plus enzalutamide from various phase 3 trials. Now, I'd like to bring to your attention that these PARP inhibitor combinations are approved with different indications in the United States and in the European Union. And they continue to get approved in various other countries. So the combination of abiraterone and a PARP inhibitor, whether it is olaparib or niraparib, they are approved for patients who have new metastatic castrate-resistant prostate cancer, and they have BRCA1 or BRCA2 mutations in the cancer cells or they have germline BRCA1 and BRCA2 mutations. Enzalutamide and talazoparib combination is approved in the United States for patients with metastatic castration-resistant prostate cancer with BRCA1 and BRCA2 mutations, but also several other DNA repair gene mutations. And that's a big difference as far as approval is concerned in the U.S. In the European Union, for our patients who are listening from European Union, the combination of abiraterone and olaparib and enzalutamide and talazoparib are approved for patients with metastatic castrate-resistant prostate cancer where chemotherapy is not clinically indicated, regardless of whether they have mutations in the DNA repair genes or not. And the combination of abiraterone and niraparib is only approved for patients with metastatic castrate-resistant prostate cancer with BRCA1 and BRCA2 mutation. So I just wanted to outline the different indications in the United States and in the Europe. Dr. Grivas: Thank you so much, Neeraj. So eloquent and very relevant to multiple patients globally, as you pointed out, with some differences in terms of the regulatory approval and availability of those agents in different countries. So great insights. Maybe we'll ask you 1 more question again since we are doing the highlights of the year. Another very important area of therapeutic development has to do with these novel agents that target the prostate cancer cells, and we call them theragnostics as a broader term. And I will let you explain what that means maybe in lay terms for our audience. And specifically, if you can comment on the recently presented PSMAforetrial at the ESMO meeting in Madrid with lutetium-177 PSMA. What are the implications of these results for our patients, and what is the r

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this Meaningful Conversations podcast, Dr. Richard Lee talks to Dr. Tara Sanft and Dr. Biren Saraiya about what people with advanced cancer should know, including the value of palliative and supportive care and ways to talk with their families and healthcare teams about their health care wishes. Meaningful Conversations is a Cancer.Net blog and podcast series that describes the important discussions people may need to have with their providers, caregivers, and loved ones during cancer and offers ways to help navigate these conversations. Dr. Lee is a Clinical Professor in the Departments of Supportive Care Medicine and Medical Oncology at City of Hope Comprehensive Cancer Center and serves as the Medical Director of the Integrative Medicine Program. He is also the 2023 Cancer.Net Associate Editor for Palliative Care. Dr. Sanft is a medical oncologist and Chief Patient Experience Officer at Smilow Cancer Hospital, the Medical Director of the Yale Survivorship Clinic, and Associate Professor of Medicine in Medical Oncology at Yale School of Medicine. Dr. Saraiya is a medical oncologist at Rutgers Cancer Institute and Associate Professor of Medicine in the Division of Medical Oncology, Solid Tumor Section at the Rutgers Robert Wood Johnson Medical School. Both Dr. Sanft and Dr. Biren are members of the 2023 Cancer.Net Advisory Panel for Palliative and Supportive Care. View disclosures for Dr. Lee, Dr. Sanft, and Dr. Saraiya at Cancer.Net. Dr. Lee: Hi, my name is Richard Lee. I'm a clinical professor here at City of Hope and also the Cherng Family Director's Chair for the Center for Integrative Oncology. I'm really happy to be here today and talking about the topic of advanced care planning. And I'll have Dr. Tara Sanft and also Dr. Biren Saraiya introduce themselves as well. Dr. Sanft: Thanks, Dr. Lee. I'm Tara Sanft. I'm a breast medical oncologist at Yale Cancer Center and Smilow Cancer Hospital in New Haven, Connecticut. I am board certified in medical oncology and hospice and palliative medicine. I do direct the survivorship clinic, which is an appropriate place for advanced care planning that we can touch on today. I'm really happy to be here. Dr. Saraiya: Hi, my name is Biren Saraiya. I'm a medical oncologist focused on GU medical oncology and also a board-certified palliative care physician. I'm at Rutgers Cancer Institute of New Jersey. My focus is on decision-making. My research interest in decision-making and end-of-life planning for patients with serious medical illnesses. And I do a lot of teaching on this topic at our medical school. And I'm also glad to be here, and I do not have any relevant financial disclosures. Dr. Lee: Thank you so much for both of you for being here. I should also add, I don't have any relevant financial or disclosures, conflicts of interest. Dr. Sanft: Thank you. I'd like to add that I do not either. Thanks for the reminder. Dr. Lee: Yes. Thank you both. And so this is a really important topic that we deal with when we see patients, especially those with more advanced cancer. Could you talk about when we say advanced cancer, what does that really mean? Dr. Saraiya: When I think of advanced cancer, it is either cancer that has come back, recurred, or that is no longer curable, no longer something that we can't completely get rid of. So many times, it is what we call stage four cancer. Each cancer is a bit different. So it's a general rule of thumb, but not necessarily intelligible for every single cancer. But that's what I mean when I say advanced cancers to my patients. Dr. Lee: How about yourself, Dr. Sanft? Do you use a similar concept, or is it a little bit different? Dr. Sanft: I agree with all that's been said. Advanced cancer typically involves the spread of the cancer to other sites outside of the primary site. And the strategy tends to be a chronic long-term management strategy rather than curative treatment, although not always. And as our science becomes more advanced and sophisticated, these terms can apply to people with all different tumor types and locations of involvement, and that's really exciting. But in general, advanced cancer is very serious and can often be life-threatening and needs to be dealt with always. Dr. Lee: And that leads into the next question, which is, if it's not possible to completely cure the cancer, does that mean there's no treatment available for these patients? Dr. Sanft: Absolutely not. Does it mean that there is no treatment? Even when anti-cancer treatment may not help the situation, there is treatment. And I think as palliative care professionals, in addition to being medical oncologists, treating symptoms and treating suffering that comes with symptoms from cancer is always on the table from the time of diagnosis through the balance of life. And when a diagnosis comes through that is life-threatening or advanced or stage four, it is very common to pursue anti-cancer treatment, sometimes many different types of treatment. And it's very rare that someone with a new diagnosis of advanced cancer would not qualify for any anti-cancer treatment. Dr. Lee: Thank you. And moving along with that same concept, Dr. Saraiya, could you talk about what are the kinds of treatment options available to patients with advanced cancer? And then could you comment a little bit what Dr. Sanft was talking about, which is also there's anti-cancer treatments, but then there's also these treatments that help with quality of life and symptoms. And can they be coordinated together? Are we choosing one or the other? Dr. Saraiya: That's a great question. The way I think about this is I always want to focus on what's important for the person in front of me, what's important for the patient. And so even when there is no cure for the cancer, it is certainly treatable. And as Dr. Sanft pointed out, we have many treatments, many types of treatments. So they are delivered by someone like me or Dr. Sanft who are medical oncologists, but also by our colleagues in radiation and surgery and our colleagues in palliative medicine. So it depends on what the symptoms are; we can discuss how to best address it. And sometimes it requires radiation, short course of radiation. Sometimes that's the most effective thing. Sometimes it requires medicines that are by mouth or chemotherapy that are intravenous or by mouth or immunotherapy or different kinds of newer agents that we are using these days. So they can be delivered under the care of a medical oncologist. We can also have sometimes something that's very painful, and the surgeon can remove it. And that is also just as good of an option. So what we choose to do depends on what the objective is, what we are trying to accomplish. And to me, at any point in time I see a patient, every single person I meet with, my goal is how do I help them live better? What's important for the quality of life? And many times is what I do as a medical oncologist, many times it's just listening to them and talking to them and providing support, either myself or my staff or social work. And many times, it's my colleagues in palliative medicine who are helping me care for their symptoms such as pain, other symptoms that I may have a hard time addressing by myself. And so we call on their help when we can't address it. Dr. Lee: We've touched upon the topic of palliative care and supportive care, that terminology. And I'm wondering if you could expand on that so we have a common understanding. And how is that different than hospice care? Dr. Saraiya: This is how I explain to my patients and my students, which is to say, when I went to medicine and I asked my students this question, how many times do we actually cure cancer or cure anything, forget cancer, just anything? And the fact is that most times we don't cure many diseases. So things like high blood pressure, diabetes, high cholesterol, heart disease, liver disease. We don't cure things outside cancer as well. But what we do is we help patients live long and well for long periods of time. We focus on quality of life. And in essence, we are providing palliative care. So I define palliative care anything that helps patients live better or live well. Sometimes we can cure things as well. So many cancers are curable. But let's say you have extensive surgery for a cure of the cancer, but you have pain from the surgery. We certainly help give you pain medicines. That's palliative care. And so for me, palliative care is anything that we do to help alleviate patient's symptoms. It can be delivered by the surgeon who prescribes pain medicine postop, by radiation doctor, who helps with palliative radiation, by medical oncologists like myself and Dr. Sanft, who give medicines for nausea, vomiting, or other symptoms that either the treatments or the cancer itself is causing. When we need help of our colleagues who specialize in this is specialized palliative care. And some just call it supportive care. It's just a naming terminology. As long as we are helping patients live better, any intervention we make to me is palliative and supportive care. At a time when we agree, both patients and we agree that look, our focus is just on co

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. ASCO’s first clinical trial is the Targeted Agent and Profiling Utilization Registry, or TAPUR Study. This clinical trial is intended for people with advanced cancer without other treatment options available, and whose cancer has at least one genomic variation that can be targeted with specific drugs. In this podcast, Dr. Richard Schilsky discusses the TAPUR study and explains why it is significant. He also discusses what participants can expect. Dr. Schilsky is the Principal Investigator for the TAPUR study. He is also the former Chief Medical Officer for ASCO and Professor Emeritus at University of Chicago. View Dr. Schilsky’s disclosures at Cancer.Net. Dr. Schilsky: Hi, everyone. My name is Richard Schilsky and I'm the principal investigator of the ASCO TAPUR Study and the former Chief Medical Officer of ASCO. I'm happy to give you an overview and update about the study today. By the way, TAPUR is an acronym that stands for Targeted Agent and Profiling Utilization Registry. Hopefully, the reason for naming it that will become clear as you listen. The TAPUR study was conceived in 2013 and launched in 2016, and was based on the observation that there was a rapid increase in testing the tumors of patients with advanced cancer for gene mutations that might be contributing to the growth of the tumor, so-called genomic profiling, in the hope of finding a genomic alteration that could potentially be treated by a drug that was already FDA-approved for a different tumor type than what the patient had. Meaning, in order for the patient to receive the drug, it would have to be prescribed off-label. The challenge with prescribing the off-label use of a drug is that most insurance plans don't cover the cost of treatment. Additionally, even if the patient were able to receive the drug, there was no mechanism for the oncology community to learn from the patient's treatment experience. The TAPUR study has managed to address these challenges by providing access to FDA-approved drugs at no cost to the patient and providing treatment results to the oncology community regarding the effects of off-label use of the treatments being studied. Now, TAPUR is a clinical trial, and its primary objective is to describe the anti-tumor activity and toxicity of commercially available targeted anti-cancer drugs prescribed for treatment of patients whose tumors have a genomic alteration known to be a drug target or to predict sensitivity to a drug. TAPUR was designed to be simple for providers and patients. It's a phase 2 study, meaning that we're aiming to learn about efficacy and safety. It’s prospective, that is, it enrolls patients going forward. It is not randomized. Everybody gets a treatment based on the genomic profile of their tumor and the available treatments in the study. It's a multi-basket study. That is to say, multiple therapies are available on the study that are targeting multiple genomic alterations. And it's a pragmatic study. TAPUR attempts to replicate routine clinical care. It's exempt from FDA oversight. It provides oral drugs that can be shipped directly to the patient's home after the first visit. Now, as I said, the TAPUR study was launched in March of 2016. And as of this month, it's still going strong, with more than 2,700 patients having been enrolled at 267 locations in 28 states. So how does the study work? Well, a patient's physician has results of a genomic profile of the patient's tumor and determines that a study drug might benefit the patient. The patient then decides to participate in TAPUR and gives their informed consent. A molecular tumor board, which is a group of experts convened by ASCO, is available to consult regarding the proposed treatment or to provide alternative treatment options for the patient. A participating pharmaceutical company, and there are 10 right now, provides the study treatments at no cost to the patient. The patient is cared for by their own oncologist, receives a standard dose of the drug, and is evaluated at standard intervals to see if the treatment is working and if they're having any side effects. ASCO has convened an independent data and safety monitoring board of cancer experts that periodically reviews results and determines whether treatment is promising for a particular cancer type and genomic alteration. That's what we call a cohort in the study. Once the data are finalized, ASCO publishes the study findings in peer-reviewed journals to inform clinical practice and future research. So let me give you an example. There are specific molecular alterations that often appear in tumor cells that are important for driving the growth and progression of the cancer and can be targeted with specific drugs that interrupt those abnormal molecular pathways. Many of these alterations occur at low frequency, meaning in less than 5% of tumors of any given type. The benefit of the TAPUR trial having a basket design is our ability to evaluate multiple therapies simultaneously to target multiple low-frequency alterations, which ultimately offers more treatment options to patients who wish to participate in the study. If the TAPUR study were set up looking to target only a single genomic alteration, we would potentially have to screen hundreds of patients in order to find one who is appropriate for the trial, which also means hundreds more would still be left without treatment options. But because TAPUR evaluates multiple treatments and multiple genomic alterations simultaneously, we found that about two-thirds of patients who were screened for the trial ultimately enroll. A specific example of a drug and targeted gene alteration on TAPUR is the use of the treatment combination pertuzumab plus trastuzumab in tumors with ErbB2 amplification or mutation. Now, you may be aware that ErbB2 is a gene that is synonymous with the HER2 gene that is frequently amplified or overexpressed in patients with breast cancer. And this drug combination, pertuzumab and trastuzumab, is FDA-approved for treatment of patients with breast cancer. But in the TAPUR study, we found multiple tumor types outside the FDA-approved label that can benefit from this treatment if an ErbB2 alteration is detected, including patients with colorectal cancer, endometrial [uterine] cancer, biliary tract cancer, and lung cancer. To learn more about TAPUR, please follow our progress at the ASCO website. In an effort to provide up-to-date information about cohorts that are available for enrollment on the TAPUR study, ASCO launched a public-facing status report in March of 2023. So first click on www.tapur.org. Click on the link to the ASCO website. From there, select study participation at the bottom of the page. Once at the study participation page, click on the link to see a list of study cohorts that are currently enrolling. The report updates daily, providing viewers with an up-to-date list of available study cohorts based on their genomic alterations. It's important to note that study cohorts are available on a first-to-enroll basis. You can also find information about current results from the TAPUR study on the study results page. So what have we learned so far? Thus far, we've publicly reported results on 29 cohorts of patients. 17 gave a positive signal of treatment activity, 12 were negative. Now we feel it's just as important to report on the negative results as the positive results. If the treatment is unlikely to be effective for patients, it's important to inform the oncology community because all of the drugs in the study are commercially available and could be prescribed to a patient. Enrollment to patients on TAPUR is very representative of the U.S. population. The study has broad eligibility criteria that allows more patients to enroll, including patients with an ECOG performance status of 0 to 2 and younger patients. Some treatments allow for adolescent patients as young as age 12 to be enrolled in the study. We hope the oncology community finds value in the TAPUR study. Physicians have the opportunity to contribute to research and participate in publications and to contribute more knowledge in the field of oncology. TAPUR provides guidance on interpreting genomic reports via the molecular tumor board and provides additional treatment options for patients. Institutions obtain insights on potential new uses of existing drugs and their side effects, and TAPUR data can inform updates to clinical practice guidelines. And patients receive access to drugs not available as standard of care. Patients may be able to receive oral drugs at their home and limit their commute to clinic. And of course, participation in the study provides an opportunity for patients themselves to contribute to knowledge about cancer treatments. To find a clinical site offering the TAPUR study, please visit the TAPUR website again, www.tapur.org and select “Participating Centers.” This will lead to a searchable map of participating sites and includes the site-specific contacts. Contact the primary contact listed for that site. Thank you for listening to this update on the ASCO TAPUR study and enjoy the rest of your day. ASCO: Thank you, Dr. Schilsky. Learn more about cli

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this podcast, Cancer.Net Associate Editor for Lung Cancer, Dr. Charu Aggarwal, and Cancer.Net Specialty Editor for Thymoma, Dr. Ryan Gentzler, discuss what people with early-stage non-small cell lung cancer should know about their treatment options before and after surgery, called neoadjuvant therapy and adjuvant therapy, respectively. Dr. Aggarwal is the Leslye Heisler Associate Professor of Medicine in the Hematology-Oncology Division at the University of Pennsylvania’s Perelman School of Medicine. Dr. Gentzler is a thoracic medical oncologist and Associate Professor of Medicine in the Division of Hematology/Oncology at the University of Virginia (UVA) Comprehensive Cancer Center. View disclosures for Dr. Aggarwal and Dr. Gentzler at Cancer.Net.  To begin, Dr. Gentzler will discuss what people with early-stage non-small cell lung cancer should know about neoadjuvant treatment options before lung surgery. Welcome, Dr. Gentzler. Dr. Gentzler: Hi, this is Ryan Gentzler from the University of Virginia. We're here to discuss the role of neoadjuvant chemotherapy and immunotherapy for the treatment of locally advanced non-small cell lung cancer. So first, I thought I'd address some of the data and definition of what is neoadjuvant treatment. So when we think about treating lung cancer that is not metastatic, that is earlier stage disease, there typically involves multimodality treatment. Sometimes these lesions or tumors can be very small and can be stage I and treated with surgery alone or perhaps radiation alone and no further treatment is needed. But the vast majority of lung cancers that are considered early stage are in fact either larger tumors, involve lymph nodes, and typically fall into the category of stage II or III lung cancers. And these are cancers that often require multiple treatments beyond the local surgery approach alone. When we think about how we deliver that treatment, it can either be given before surgery or after a surgery. If we give treatment before a surgery, we call that neoadjuvant. If it is given after the surgery, we call that adjuvant. And most of the data that we have today in lung cancer uses one or the other of these approaches, and we don't typically give treatments both before and after, at least in terms of the chemotherapy part of that treatment. Historically, most of the data exists in the adjuvant treatment of lung cancer going back several decades that showed that the benefit of chemotherapy after a surgery, particularly for those with stage II and stage III lung cancer, derived a clear benefit of survival by giving chemotherapy after surgery. More recently, with the advent of immune therapy, which we have used in patients with stage IV lung cancer as well as those with stage III lung cancer who cannot undergo surgery, those immunotherapy drugs have been shown to improve overall survival and improve clinical outcomes for a wide range of patients with more advanced disease. And so in the last 4 or 5 years, we have really looked at new trials that have added immunotherapy in what we call perioperative space, either before surgery or after surgery for those that have surgically resectable disease. I'm going to focus on the neoadjuvant approaches that we have seen today, and this largely all started with data from Patrick Forde out of Johns Hopkins and Jamie Chaft from Memorial Sloan Kettering looking at single agent treatment with nivolumab immunotherapy. This was no chemotherapy given for 3 treatments prior to or three cycles prior to surgery. And that trial demonstrated a high degree of patients with tumor reduction and more importantly, we saw that the pathologic response, meaning how much tumor was left under the microscope at the time of surgery, was higher than what anyone anticipated with just immunotherapy alone. That launched a whole series of larger randomized prospective trials evaluating largely the combination of chemotherapy and immune therapy prior to surgery. Now, before we get into some of the results of these trials, I really wanted to emphasize some of the theoretical advantages to neoadjuvant approach. Now, the first potential advantage of giving neoadjuvant treatment is that we know when you start with immunotherapy and chemotherapy regimens and that's the first type of treatment, everyone is guaranteed to get that treatment. And we know that the completion rate prior to surgery is higher than it is after surgery. These patients can get all of the prescribed treatment and will be more likely to get it than if they get it after surgery. So this is one advantage. The other is potentially starting these medications which go throughout the body and treat the cancer, wherever it may be, earlier. We know that one of the risks of all cancers, but lung cancer in particular, is that even with good surgery and removing all of that cancer, there is a chance that there are cancer cells left behind, which leads to risk of recurrence in the years to come after surgery. Naturally, if we start the treatment that can eliminate those cancer cells, wherever they may be, and do that first, perhaps we catch this earlier with fewer cells that have escaped and have a more likely chance of success of eliminating the cancer and resulting in a cure. The third, I think, is one that we still have yet to learn more about, but if we give immunotherapy in particular, these are medications that activate the immune system, particularly the type of immune system cell called a T cell. If that T cell is able to recognize tumor cells, it is more likely to be able to continue to attack those tumor cells. And if we give that treatment prior to removal of the tumor, perhaps that activates the immune system in a more robust way that it can go after these cancer cells and eliminate those that are left behind after the surgery. If you give the immunotherapy after a surgery and the bulk of the tumor, most of the cancer cells have been removed, it may be harder to find those antigens or foreign proteins that are expressed in cancer cells. So the immune system may not be as robustly able to go after cancer if you give it solely after a surgery. Another potential advantage of neoadjuvant approaches is that it really helps us learn as oncologists how well a cancer is responding to a treatment. If we give these treatments for 4 cycles after a surgery, we don't know whether it's eliminating those residual cancer cells or whether it is totally ineffective. If we give it before a surgery and we see that there is tumor reduction or that there is a complete elimination of the cancer, we know that that treatment was an effective treatment at attacking the cancer cells and eliminating them. We know that the cancer was sensitive to that treatment. We can then better prognosticate how well the patients are going to do after surgery. We know based on the latest data that if you achieve what we call a pathologic complete response with chemotherapy and immunotherapy prior to surgery, meaning there are no cancer cells left when we look at that surgical specimen under the microscope, we know that those patients have a much better likelihood of surviving for longer periods of time than those who have active cancer at the time of surgery after prior treatment. And so neoadjuvant approaches allow us in a 2-month time frame to get a great sense of how well our treatments are working and able to prognosticate outcomes based on how well those cancer cells have been eliminated at the time of surgery. One large phase 3 trial called the CheckMate 816 trial was a randomized phase 3 trial and that enrolled patients with stage IB through IIIA non-small cell lung cancer using the old staging system of the 7th edition. These would all now be categorized as stage II and stage III non-small cell lung cancer patients. And it randomized these patients to 3 cycles of chemotherapy plus nivolumab, which is an immunotherapy drug, and compared that to patients treated with chemotherapy alone for 3 cycles. After these 3 cycles of chemotherapy, which is about a 9-week time frame, patients had surgical resection of their tumors. And then after surgery, patients received no further treatment, although treating physicians were allowed to give additional treatments like chemotherapy or radiation if they thought it would be beneficial for these patients, although it was not mandated by the study. One of the first results we saw from this study was that there was a much higher rate of pathologic complete response of 24% of patients achieving a path CR [pathologic complete response] with the nivolumab plus chemotherapy combination compared to only 2.2% with chemotherapy alone. This was highly statistically significant and demonstrated a clear benefit for those receiving the immunotherapy. The other main endpoint of this study was event-free survival, meaning that the time that the patients were alive and without any significant event like cancer progression or death after the enrollment of the trial. And in this analysis, the median event-free survival was significantly longer in those who have received the immunotherapy plus chemotherapy combination prior to surgery. One

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this podcast, Dr. Allison Kurian and genetic counselor Kristen Mahoney Shannon talk about what people should know about genetic testing and hereditary breast cancer, including what to expect when meeting with a genetic counselor, ways to reduce your risk of developing cancer, and talking about genetic test results with family.  Dr. Kurian is a Professor of Medicine and of Epidemiology and Population Health at Stanford University School of Medicine, and Director of the Stanford Women’s Clinical Cancer Genetics Program. She is also the 2023 Cancer.Net Specialty Editor for Breast Cancer. Ms. Shannon is a senior genetic counselor and Director of the Cancer Center Genetics Program and Director of Genetic Counseling for the Massachusetts General Hospital Department of Medicine. She is also a 2023 Cancer.Net Advisory Panelist. View disclosures for Dr. Kurian and Ms. Shannon at Cancer.Net. Dr. Allison Kurian: I'm Allison Kurian. I am a professor of medicine, oncology, and epidemiology and population health at Stanford University. And I am speaking today with my colleague, Kristen Shannon, who will introduce herself. Kristen Shannon: Hi, it's great to be here. My name is Kristen Shannon. I am a genetic counselor and the director of cancer genetics at Massachusetts General Hospital in Boston. And I have no financial relevant disclosures to report. Dr. Allison Kurian: Thank you, and I have no relevant financial disclosures either. Very good. So today we will be talking about breast cancer and inherited risk and genetic testing. And let me start by providing a definition of a genetic or hereditary condition. So the way we think about this is something that has a high risk for developing a disease, not a certainty, but a high risk, and runs in families, generally because of a genetic finding that we can identify. And that typically is identified through sequencing, testing of blood or saliva samples, and typically allows us to find a change that we know is clearly associated with disease. A good example for breast cancer are the genes BRCA1 and BRCA2, which some may have heard of, and we will talk about further. So that is just an example, and we will get into more of the details of this as we go on. But I think the point is something that runs in families often is seen with the trait, so for BRCA1 or BRCA2, that would be breast cancer or ovarian cancer, affecting people in every generation. And having what we call for these kinds of genes an autosomal dominant inheritance pattern, so inherited from either parent. And taking only 1 copy that is not functioning to give a person higher risk of the condition. So that's sort of a bit of the basics here on genetic or hereditary risk. And just to give a sense of how common hereditary breast cancer is, we think that in general this may account for, I would say, somewhere between 5% to perhaps 10% of cases of breast cancer. And Kristen, please jump in and tell me if you think differently. But that would be my ballpark. And I think probably the majority of those are the BRCA1 and BRCA2 genes that I mentioned, although there are others that we are recognizing are playing more of a role than we thought, and we'll discuss those, too. So let me give you a chance to continue and respond, Kristen. Kristen Shannon: Yeah, no, I totally agree. And I was thinking that maybe I could talk a little bit about some of the features that are suggestive that there could be one of these inherited breast cancers in the family, because recognizing these signs of hereditary breast cancer can be super important for early detection and prevention of breast cancer. So first, multiple cases of breast cancer within the family, especially among close relatives like parents, siblings, children, those can be a sign that the cancer is inherited. Another important sign is early age of onset of disease. So breast cancer diagnosed at a young age, typically before the age of 50, might point towards hereditary risk. And it's not always the case, but it's something to be aware of. Also, if there is a history of ovarian cancer in the family, especially if you see it in conjunction with breast cancer cases, that's a significant sign that there could be something inherited in the family. And while it's rarer, male breast cancer can also be associated with hereditary gene mutations. So if there's a history of male breast cancer in the family, it's definitely something to think about in terms of hereditary risk. Multiple cancer types in the family can also be another clue. It's not always just breast and ovarian cancer. If you see a family history of both breast and ovarian cancer or pancreatic cancer or prostate cancer within the same family, that also might be a sign of an inherited cancer syndrome. For individuals of Ashkenazi Jewish descent, it's worth noting that they have a higher prevalence of certain gene mutations in specific genes, specifically BRCA1 and BRCA2, which Dr. Kurian has mentioned before. So a family of history of breast or ovarian cancer in an Ashkenazi Jewish individual should be noted as a higher sign that this cancer could be due to an inherited gene. And lastly, if someone has had breast cancer in both breasts, that's called bilateral breast cancer, and that might indicate hereditary risk. It's important, though, to remember that it's not just about any single sign in isolation. You really need to take a look at the bigger picture and the bigger context of the family. So if you notice any of these signs in your family, it's a good idea to seek guidance from a health care professional, like a genetic counselor or a medical oncologist, and they can help assess the family's risk and recommend genetic testing if needed. Dr. Kurian, did I forget anything or leave anything off? Dr. Allison Kurian: Perfect as always. I will just add a little bit here in terms of the specific gene names that we think about, because sometimes it helps people to have sort of a list in their minds, not that we expect you to remember the whole alphabet soup of these different genes. And let me just say that I think it's always a bit of a hodgepodge, some of these names. I used to wonder how people come up with these names, and often there's a bit of a history there. But I will just go through a few of them. We now have some practice guidelines, and they are basically put together by a group of experts who review all the evidence frequently and come up with recommendations. And so there is a list in these guidelines of basically which genes we think are appropriate to test for breast cancer in families, because there's enough evidence to suggest that. And so in addition to BRCA1 and BRCA2, the ones that I think of as the most important, and I'll want to hear Kristen's thoughts about this, too, but the ones that we see most often are called ATM. Sounds like a cash machine, unfortunately not, but ATM. CHEK2, C-H-E-K-2, and then one called PALB2, which stands for Partner and Localizer of BRCA2, and is a lot like BRCA2 in its risks. There are some other genes that give breast cancer risks that are less common. One of them, CDH1, is a gene that also causes an increased risk of stomach cancer. There are a few others that we always keep in mind. There's one called PTEN that's very rare that causes a syndrome called Cowden syndrome that I certainly haven't seen much of. Kristen may have seen more, but it's not something we see often and goes with a lot of other features in families. There are 2 genes that I think we recognize more in recent years and like to be sure we test, called RAD51C and RAD51D, and those both give increased risks. And then another one that I always think of as important here is TP53, and that is a gene that causes something called Li-Fraumeni syndrome, which has probably the highest cancer risks of which we know. There's another one, STK11, that gives some risk, NF1. We see these as being less frequent contributors. Those are the ones that I kind of keep in mind. And again, there will not be a quiz on the alphabet soup, but just so you're aware of what kinds of names you might hear. Kristen, please jump in if I've forgotten any or anything else you want to say. Kristen Shannon: No, I think that that's important. I think the only thing that I would add is that some people think when they go in for breast cancer genetic testing, they only are getting the BRCA1 and BRCA2 gene. And it's just important for people to realize that that's not really a complete test at this point, as you mentioned, Dr. Kurian. Dr. Allison Kurian: Totally agree, and thank you. Kristen Shannon: Should we move into how to prepare for a genetic counseling appointment? Dr. Allison Kurian: Please, yes. Kristen Shannon: Sure, okay. So preparing for a genetic counseling appointment for breast cancer risk can be helpful. First and foremost, we suggest that you gather your family health history. So reach out to your relatives and compile as much information as possible about your family's health background. Pay special attention to any instances of breast cancer and ovarian cancer, prostate cancer, pancreatic cancer in the family. And if any family members have had geneti

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this Meaningful Conversations podcast, Dr. Lalan Wilfong talks with social worker Lydia Mills about what people with cancer should know when discussing their goals of care with their health care team, including the ways it can help inform their treatment plan and tips for navigating the conversation. Meaningful Conversations is a Cancer.Net blog and podcast series that describes the important discussions people may need to have with their providers, caregivers, and loved ones during cancer and offers ways to help navigate these conversations. Dr. Wilfong is a medical oncologist and the senior vice president of payer and care transformation at the U.S. Oncology Network. He is also a member of the 2023 Cancer.Net Editorial Board. Ms. Mills is a licensed clinical social worker and the senior manager of supportive care services at the U.S. Oncology Network.  View disclosures for Dr. Wilfong and Ms. Mills at Cancer.Net. Dr. Wilfong: Hi, I'm Dr. Lalan Wilfong, Senior Vice President of Payer and Care Transformation for the U.S. Oncology Network. And today we're going to be talking about goals of care. Lydia, can you introduce yourself? Lydia Mills: Yeah, sure. I'm Lydia Mills, Senior Manager, Supportive Care Services. I work with practices across the U.S. Oncology Network, and I am a licensed clinical social worker. Dr. Wilfong: So Lydia, what does it mean when we talk about goals of care during cancer? Lydia Mills: Well, I think a lot of people think about what treatment is going to look like, what that prognosis is going to look like, what that end goal is going to be when they're having their treatment. I think it can be a lot broader than that. In fact, I've had some people say, “What do you mean by goals of care?” So I think it's really important to bring in, I think, the patient perspective when we're talking about this and what's important for them in addition to maybe what that cancer treatment is going to do for them physically, but also what is important to them as far as what do they want to work, are there things they want to accomplish, are there things they want to get done, are there things they want to do or see? As well as, you know, often the goal quote is to be cured, and we know that's not always the case. So what are some other things that they might want to accomplish? And, you know, I don't know from your perspective from a physician, but that's kind of what I saw with social work is kind of more what's really important to them. Dr. Wilfong: Yeah, it's so important for people undergoing treatment for cancer to have an understanding of what they're going through. I've seen patients all the time, you know, at the end of life, look at me and go, “I wish I would have made a different decision.” And that's always super hard as a physician to realize that you didn't take the time to fully understand what a patient wanted. And they went through something that they made a different decision about if they had known better. And so I think it's so important to talk about that with patients so they truly understand what treatment they're getting, what the impact of that is on their quality of life, what the duration of improvement and survival and things is. Because like you mentioned, a lot of people take therapy thinking that they're going to be cured, and we know that's not going to be the case many times. So they can really understand and make sure that they're doing things that are appropriate for them, and that are aligned with what they really want to accomplish for the time of life that they have. So it is super important about that. Any other things that you think of that are important around the goals of care for people with cancer? Lydia Mills: Well, you know, I think a lot of times when people start thinking about, well, I need to really think about getting quote things in order, right? They often think more of the financial piece. What am I going to do with my assets? They don't always stop to think about family members, relationships. Even, gosh, it's really important that we take that family trip in 6 months. You know, sometimes they just don't even always think about all those things. So I know I would always try to bring that into perspective as well, that it's not always just about, you know, the treatment and what that's going to look like and your financial aspect. But what are a lot of these other things that are important to you, your family, and your loved ones? Dr. Wilfong: I know so many times people have these life events that they want to make sure that they are at, whether that's a wedding or a birth of a child or things. And being able to plan appropriately for that is so important. I just remember a story I heard from one of my physician colleagues recently where a patient who had a terminal illness was going to get married, and they really wanted to get married is a big thing, and they kept putting it off and putting it off. And finally, she convinced them to actually get married. And the spouse, after the patient had died, was so appreciative of the physician pushing them to get that done because it meant the world to him and to her to have that actual wedding event. And so just things like that are so important for patients to understand and so they can plan for their lives. So Lydia, when do you think these conversations should take place? Lydia Mills: I honestly think the earlier the better. I mean, I think sometimes people want to wait and kind of see how things are going. And there might be an initial discussion when they're first diagnosed and treatment first starts. But I really think the earlier you can start talking about this and then keep checking in with the patient. And I would encourage patients to let those physicians know, like, hey, I really want to do this trip, or I really need to make it to graduation, whatever that might be, because depending on what that trajectory looks like, things change so frequently, or they can. And so, if you have kind of set milestones in your head of when to have the conversation, that may not always work for the planning for the patient and their family. Dr. Wilfong: I completely agree. I think early and often is a phrase I like to use. And it changes, like you mentioned. I mean, people with cancer undergoing therapy, things change, their life changes. And so making sure that you're always going back to my aligning the treatment that we're giving to their goals of care is so important because it changes all the time. And I think that's one thing that we get hung up on, especially as physicians. We think these conversations have to be this long, drawn out, hour to hour long discussion with patients, which there's a role and a time for that. But many times, it's just that simple check-in of, are we still on the right track? Has anything changed with you that we need to address and make sure that we stay on top of that? When we're having these conversations with patients, what typically is discussed? I mean, what do you think the main topics that a patient should expect to discuss during one of these? Lydia Mills: Yeah, well, I mean, I think, and you can chime in from a physician perspective, but I think a lot of times it is, you know, what is this treatment going to look like? How is it going to affect you? Of course people often want to know about prognosis. Again, I think it's important to expand on that and find out, you know, what is important to the patient. If you're going to be on treatment for, you know, 6-plus months or longer, tell me what do you have going on? Do you have things scheduled? I think people are afraid often to interrupt their treatment so they don't want to talk about what's important to them. They want to make sure they're there every single treatment visit versus, you know, I really did have this trip planned or there's a life event occurring. They can usually take a break if the physician knows, right? So I think it can be a variety of things, but you know, definitely what it might look like in the next few months and sometimes it's hard to go beyond that, which I think brings in the why it's important to have these conversations frequently. Dr. Wilfong: I agree. And I see so many times people don't want to talk about this stuff for themselves. It is so important for us to understand really what is important to them so we can give them the right therapy. And I would say I think people need to bring their open and honest self to these conversations so that the things that may be bugging you in the back of your mind, we want to make sure we get those out there and talk about them because I can't help you unless I know what's going on with you. So I think that's really important as well. These are hard discussions. I mean people are having to open themselves up, which is hard for a lot of people to do, to really talk about your goals, your fears. Lydia, how do patients come and bring themselves to these conversations? What can they do to prepare so that they're ready to have these? Lydia Mills: Yeah, you know, I think it's really important. You know, a lot of times patients, like I mentioned, they're used to talking about how t

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this podcast, Dr. Abby Rosenberg discusses what parents and family members of children with cancer should know about palliative and supportive care. She addresses the way palliative and supportive care is different from hospice or end-of-life care, what to expect when meeting with the palliative and supportive care team, and the ways this type of care can support children with cancer and their families. Dr. Rosenberg is the chief of pediatric palliative care at the Dana-Farber Cancer Institute and Boston Children's Hospital in Boston, Massachusetts. View Dr. Rosenberg’s disclosures at Cancer.Net. Dr. Rosenberg: Hi, my name is Abby Rosenberg. I am the chief of pediatric palliative care at the Dana-Farber Cancer Institute and Boston Children's Hospital. And today we're going to be talking about what pediatric palliative care is, maybe demystifying it a little bit, and more importantly, talking about how it can help kids with cancer and their families. I think one of the most important things to know about palliative care is that it is a specialized kind of medical care for people who live with serious illnesses like cancer. And folks who are receiving palliative care are receiving extra support to help them with complicated symptoms, pain, distress, as well as complicated decisions that they might need to make in the process of their illness. Palliative care is really intended to help enhance a person's current care by focusing on their quality of life, and not only the patient's quality of life but also the quality of life for the whole family. In pediatrics, that includes parents, siblings, and other kids who might be members of the community. The way I think about palliative care is that it is really intended to help people live their best lives for as long as possible. And so with that in mind, it can really help a whole bunch of people who are affected by pediatric cancer. And the way we do that is by delivering help through what we call an “interprofessional team.” And so a palliative care team in pediatrics includes physicians, it includes nurses, includes advanced practice providers like nurse practitioners, it includes social workers. It may also include child life specialists, psychologists, chaplains, other folks who are involved in the child's overall well-being. Palliative care can be provided at any time in a child's cancer experience and anywhere. It can be delivered while you are in the clinic, while you are in the hospital staying overnight, and we can deliver it to you at home. Some people confuse palliative care and hospice care, and those are 2 different things. So palliative care can be delivered concurrently with cancer-directed and cure-directed therapy.  And generally, when we talk about hospice, it is for patients and families who have started to understand and recognize that perhaps their cancer might not be curable, and they are making the courageous and loving decision to switch gears and focus more on quality of life without continuing cure-directed therapies. Hospice care, like palliative care, can be delivered in a bunch of different settings. And most times in pediatric hospice care, we think about delivering it to a child in their home and within their home community. Some of the things that parents often ask us when we're talking about palliative care for their kids with cancer is, how do I know if my child is ready? And how do I ask for it? The answer to the first question is that again, your child can be ready for palliative care at any time. And it's really intended to help you navigate the heart of having a child with cancer. And that can, again, include anything from making complicated decisions, processing complicated information, making plans for you and your child's future, and managing complex pain and symptoms. How you ask for it is in most pediatric cancer centers, there is an embedded palliative care team that can help you. So you can ask any of your doctors and nurses and other folks who are taking care of you and your family. The last thing I'll say about palliative care is that it is a subspecialty team of experts who are good at all of these things like communication and pain and symptom management. Most pediatric oncologists do what we call primary palliative care, and that is they help support you in all of these things, too. So they help talk to you about complicated decisions and upcoming plans. They help talk to you about what might be coming with your child's symptoms, and they really help you navigate the cancer experience. And so what we try to do in pediatric palliative care is partner with you and your oncology team so that we just become a bigger team, thinking more holistically about all of the ways we can support you and your family. I think, in the end, the message of all of this is that every person taking care of a kid with cancer is trying to help that kid to thrive. And pediatric palliative care can be a really important resource to help kids to do that to the best of their abilities. So another question that we can hear from parents and families is what to expect when the palliative care team gets called. I think at a minimum, the expectation is that you will meet more people who will be really curious about your family and your child. They will ask a lot of questions about what matters to you, what are your values. They'll ask you questions about what is happening with the child's illness, what are your worries, what are your hopes, and what they do with all of that information is they help you process it, and they help translate it into something that can work for your child's overall cancer care. Part of meeting a palliative care team is always meeting all of these different members of the team, so you'll meet doctors, nurses, nurse practitioners, social workers, perhaps chaplains, child life specialists, psychologists, all of the folks that I previously mentioned. And the reason we have those big teams is because we recognize that each member of that team can help you with a different part of your whole cancer experience. And so for example, if your faith and your spiritual community is a really big part of how you are coping with being the parent of a child with cancer. We want to connect you with that part of your own strengths and resources and figure out how to support you while you are under our care in the hospital setting. So one other thing that pediatric palliative care teams can help with is talking within your family. So sometimes we get questions about how do I talk to my child about what's happening, or how do I talk to my child's brothers and sisters about what's happening? Maybe it's a, how do I support their brothers and sisters? It could be about the challenges of being a parent with one kid in the hospital and others at home, and how do you maintain your identity as a parent? How do you still be a good parent to a large family when you have one child who's really sick with cancer? And we in palliative care really can help you with that with all of the different resources and team members that I mentioned, and we can help you talk to your other kids. We can help your kids talk to each other. We can help you think as a parent about how you can navigate the situation that no parent could ever have planned for until they're in it. The other thing that we do within palliative care and the other thing you can expect is we partner very closely with your oncology team, not to replace them or make decisions on their behalf, but more to help them know you better. And so what we do is we talk together about what we are hearing from you, about what your child might need. We provide advice, we provide recommendations, for example, for how to manage perhaps complicated symptoms. We might have conversations with you and your oncologist together in the room to think as a bigger team about how we can support your child's well-being. And we'll often ask you questions in the midst of all of this about what you think is important for your child, how you want to spend your time, how you define your child's quality of life, and how we, as a larger program, taking care of children with cancer, can do better to make sure your kid is thriving for as long as possible. ASCO: Thank you, Dr. Rosenberg. Learn more about palliative and supportive care at www.cancer.net/palliative. Cancer.Net Podcasts feature trusted, timely, and compassionate information for people with cancer, survivors, and their families and loved ones. Subscribe wherever you listen to podcasts for expert information and tips on coping with cancer, recaps of the latest research advances, and thoughtful discussions on cancer care. And check out other ASCO Podcasts to hear the latest interviews and insights from thought leaders, innovators, experts, and pioneers in oncology. Cancer.Net is supported by Conquer Cancer, the ASCO Foundation, which funds lifesaving research for every type of cancer, helping people with cancer everywhere. To help fund Cancer.Net and programs like it, donate at CONQUER.ORG/Donate.

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. The theme of the 2023 ASCO Annual Meeting was “Partnering With Patients: The Cornerstone of Cancer Care and Research.” From June 2 to 6 in Chicago, Illinois, and online, cancer researchers and clinicians from around the world gathered to discuss the latest cancer research and how to ensure that all people receive the cancer care they need. In the Research Round Up series, members of the Cancer.Net Editorial Board discuss the most exciting and practice-changing research in their field presented at the meeting and explain what it means for people with cancer. In today’s episode, our guests will discuss new research advances in treating non-small cell lung cancer, small cell lung cancer, and mesothelioma.  Dr. Charu Aggarwal is the Leslye Heisler Associate Professor of Medicine in the Hematology-Oncology Division at the University of Pennsylvania’s Perelman School of Medicine in Philadelphia, Pennsylvania. She is also the 2023 Cancer.Net Associate Editor for Lung Cancer. Dr. Melina Marmarelis is an assistant professor at the University of Pennsylvania, the Medical Director of the Penn Medicine Mesothelioma Program, and the co-director of the Molecular Tumor Board at the University of Pennsylvania. She is also the 2023 Cancer.Net Specialty Editor for Mesothelioma. Dr. Kristin Higgins is a radiation oncologist, Professor and Vice Chair in Clinical Research in the Department of Radiation Oncology at Emory University School of Medicine and medical director of radiation oncology of The Emory Clinic at Winship Cancer Institute's Clifton campus location. She is also a 2023 Cancer.Net Advisory Panelist for Lung Cancer. You can view disclosures for Dr. Aggarwal, Dr. Marmarelis, and Dr. Higgins at Cancer.Net. Dr. Aggarwal: Hello and welcome to this Cancer.Net Research Round Up podcast. Today, we will be talking about the latest research from the Annual Meeting of the American Society of Clinical Oncology from June 2023, and I'm joined today by 2 experts in the field of lung cancer. Before I introduce them, I'd like to introduce myself. I'm Dr. Charu Aggarwal. I'm an associate professor for lung cancer excellence at the University of Pennsylvania's Abramson Cancer Center. I'd now like to introduce Dr. Melina Marmarelis. Dr. Marmarelis: Hi, so happy to be here. I'm Melina Marmarelis. I'm an assistant professor at the University of Pennsylvania and the medical director of the Penn mesothelioma program. Dr. Aggarwal: And Dr. Kristin Higgins. Dr. Higgins: Hi, everyone. I'm Kristin Higgins. I am a thoracic radiation oncologist at Winship Cancer Institute of Emory University. I'm a professor and vice chair for clinical research for radiation oncology. Dr. Aggarwal: Fantastic. So today, we'll talk about relevant research as it applies to practical implications in the clinic for practitioners, but most importantly, patients with lung cancer. I'd like to start off by discussing 2 key studies, and I would love for perspectives from our faculty here. The first study I want to highlight is the ADAURA trial. This is a trial that has already sort of changed practice in most recent years when the study was presented at the Annual Meeting of the American Society of Clinical Oncology in 2020, but we have new updates on this study as of 2023. So, in brief, this was a study that looked at the value of administering an oral pill called osimertinib that is a tyrosine kinase inhibitor against the EGFR, or the epidermal growth factor receptor, in patients with non-small cell lung cancer. We know that non-small cell lung cancer is quite a heterogeneous disease with some subsets of patients having mutations that may render them increasingly sensitive to the effects of these tyrosine kinase inhibitors. In fact, these pills have been used in the metastatic setting for several years based on an improvement in overall survival. What the ADAURA study tried to do was ask the question if this pill would add an incremental advantage after receiving curative-intent surgical resection in those with early-stage lung cancer. So this study enrolled patients with stage IB to IIIA non-small cell lung cancer after surgical resection and focused only on those patients that had sensitizing EGFR mutations with EGFR exon 19 deletion or L858R mutations. Patients could receive chemotherapy after having the surgery and then were basically randomized into 2 groups, one of whom received osimertinib at a dose of 80 milligrams once daily for a total of 3 years. Patients were followed up for recurrence. We already know from the earlier results that patients who received osimertinib had a better chance of delaying the recurrence of disease. However, what we found at the Annual Meeting this year is that the administration of this osimertinib also improved overall survival, which is really what we all look for in the oncology world. If you're administering a therapy, especially for a long duration, we want to be able to see a survival benefit, and that's what we saw. In fact, in patients who received osimertinib, there was a 49% less likelihood of dying from lung cancer compared to those who did not receive osimertinib. This, I think, is practice-affirming. It may not be practice-changing because some of the practitioners started using osimertinib after its FDA approval in December of 2020, but I think it just confirms our practice as it delivers an overall survival advantage in these patients. One thing that's increasingly important is to identify patients who have this mutation, so now we have efforts underway locally as well as nationally to perform molecular genotyping on all patients with lung cancer so that we can adequately and appropriately treat those with early-stage lung cancer following curative resection or following surgery. Melina and Kristin, what are your thoughts? Dr. Marmarelis: Well, I think these results are really important because it did, as you say, affirm kind of what we're already doing, but I think the most convincing part of this for me is the prevention of spread of disease to the brain. This is not comparing osimertinib after surgery versus osimertinib ever, which I think is a difficult part about interpreting this trial. But I think the fact that it prevented disease from going to the brain is really meaningful to everyone, to patients, to the physicians that are caring for them, so I think that's a really important endpoint. Dr. Higgins: I agree with Melina. I think this is really exciting for our patients. It's exciting to have more treatment options for early-stage lung cancer. I think patients that are diagnosed with early-stage lung cancer are highly motivated to do everything they can to improve their likelihood of being cured. So I tend to have a lot of conversations about side effects and toxicities with patients that have questions and are sort of wondering how it will affect their quality of life, and of course, that is an important piece of it because patients that do have curable lung cancer are probably starting off with a better overall quality of life, but I think generally speaking, our patients have tolerated it well. I'm also kind of excited from a radiation oncology point of view. We treat patients with stereotactic body radiation therapy [SBRT] that are medically inoperable. And we have another trial with a cohort looking at osimertinib for those patients that have EGFR mutations, too, and that's ongoing, again, applying the same concept of trying to really use these SBRTs that work really well in the advanced setting, moving them into earlier stages of disease to help us care for more patients. So overall, I think it's really exciting, and I think it's a huge win for the clinical research community. Dr. Aggarwal: Well, that's wonderful. And I think this certainly advances the field as this is the first targeted therapy approved for patients with early-stage non-small cell lung cancer. I should add that AstraZeneca, the company that makes this drug, has provided institutional research funding to my institution, and I also serve as an advisor to them, but I was not involved personally in the research of this clinical trial. I'd like to move on but stay within the field of early-stage lung cancer and talk about another study called the KEYNOTE-671 study, and this is important because it really applies the idea of using immunotherapy before and after surgical resection in patients with early-stage lung cancer. Just to give a little bit of background to our listeners, we now have 3 approvals for the use of immunotherapy in patients with early-stage lung cancer. Two of those are in the adjuvant setting, meaning that if a patient undergoes surgical resection or surgery for early-stage lung cancer, they can receive either atezolizumab or pembrolizumab following that surgery, and that has been shown to improve outcomes in terms of reducing the chances of recurrence. We also have another approval, which is the third approval in early-stage lung cancer, where 3 cycles of chemotherapy and immunotherapy are administered prior to surgery, also called as the neoadjuvant chemo-immunotherapy approach. This drug that has been approved in combination with chemotherapy is ni

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. The theme of the 2023 ASCO Annual Meeting was “Partnering With Patients: The Cornerstone of Cancer Care and Research.” From June 2 to 6 in Chicago, Illinois, and online, cancer researchers and clinicians from around the world gathered to discuss the latest cancer research and how to ensure that all people receive the cancer care they need. In the Research Round Up series, members of the Cancer.Net Editorial Board discuss the most exciting and practice-changing research in their field presented at the meeting and explain what it means for people with cancer. In today’s episode, our guests will discuss new research in symptom tracking and improving health equity in childhood cancer. First, Dr. Fay Hlubocky discusses research on new ways of tracking symptoms in order to improve outcomes in people with cancer. Dr. Hlubocky is a licensed clinical health psychologist with an expertise in psychosocial oncology and a health care ethicist at the University of Chicago. She is also the 2023 Cancer.Net Associate Editor for Psychosocial Oncology. You can view Dr. Hlubocky’s disclosures at Cancer.Net. Dr. Hlubocky: Welcome. I'm very glad that you are able to join us today. My name is Dr. Fay Hlubocky. I am honored to serve as the Cancer.Net Associate Editor for Psychosocial Oncology. I'm a clinical health psychologist specializing in psychosocial oncology at the University of Chicago Medicine. Psychosocial oncology centers on addressing the emotional needs of patients, caregivers, and clinicians from clinical research and educational perspectives. I have no conflicts of interest to report today. Today, we will discuss research on quality cancer care that was presented at the 2023 ASCO Annual Meeting. The theme for this year's meeting selected by the 2022-2023 ASCO President, Dr. Eric Winer, required all attendees to critically examine how interactions between clinicians and patients have changed over the years. “Partnering with Patients: The Cornerstone of Cancer Care and Research” centered on the need to observe what has been improved, what has worsened, and what can be achieved to make interactions between clinicians and patients better. The extraordinary quality and psychosocial care research presented at this meeting honored and fulfilled Dr. Winer's theme. For example, one session centered on the use of novel informatics technology to carry out research and care in the cancer clinical setting. This session, entitled, “Implementing Innovation Informatics-based Technologies to Improve Care Delivery and Clinical Research,” illuminated the current research progress of implementation for emerging information technology innovations in cancer care delivery. This session was designed to help oncologists and cancer care team to evaluate whether and how to integrate these innovations into their own clinical context. One outstanding research presentation was by Dr. Monika Krzyzanowska from Toronto's Princess Margaret Hospital called, “Implementing ePROs in the Real World Oncology Practice,” where she emphasized the importance of not only identifying and monitoring patient-reported outcomes or specific symptom burdens such as pain, fatigue, depression, or anxiety in the clinic, but yet they need to be monitored across the patient's treatment course well into survivorship at different time points, including at home. Therefore, there is a need for a standardized approach of identifying symptoms from patients because as Dr. Krzyzanowska said, patients forget to report even distressing symptoms, and clinicians at times are not always prepared to obtain these symptoms from patients. Historically, in the clinic setting and as patients receive treatment in the chemo suite, we have moved from paper and pencil clinical assessments to the use of robust assessments via electronic medical records systems in both the clinic and subsequently while patients are at home. She reported that more than 10 randomized clinical trials examined the benefits of remote monitoring for patients who undergo mostly systematic therapy with consistent improvements in both symptom control and other outcomes, including survival. She provided very robust real-world and life examples of successful implementation of patient symptom monitoring systems. For example, these have shown consistently that there's a need of improvements in symptom control, but improvement with the other outcomes. To date, she reported on several ongoing initiatives, including a large oncology community practice in Arkansas, who reported on their preliminary initial experiences with an assessment platform of 1,000 patients on systemic therapy who reported symptoms on a weekly basis. This team identified a very high recruitment rate of 79% with amazing retention rate at 88% at 6 months, dropping to about 67% at 12 months. Another real-world implementation example she noted is the work by the National Cancer Institute-funded SIMPRO consortium project, where 6 cancer centers evaluate symptom burdens in 2 different clinical scenarios: patients receiving systematic therapy and patients recovering from surgery. Here, patient data and symptoms are collected via an EMR-based E-system to readily respond to patient needs. The preliminary data and a whole host of research presentation centered on SIMPRO at the Annual Meeting showed that it was feasible, but yet a dynamic design is needed to address any operational and technical barriers for optimal implementation. Ideal partnerships between oncologists, cancer teams, patients, administrators, as well as the IT team is needed for optimal implementation as Dr. Krzyzanowska emphasized. Once these interventions are implemented, a study of sustainability of consistent patient reporting with adequate follow-up by team members, such as nursing, is important for long-term practice success. Finally, she reports that the future research of ePROs evaluation will involve novel approaches, such as clinical teams that will need to gather more complex data, including the use of dynamic approaches, such as wearable technologies, machine learning to address barriers and to improve the overall patient experience. In fact, a specific example of this type of research which reported on both the benefits and barriers centering on ePROs trials at the ASCO Annual Meeting included a very large randomized controlled trial by a Danish team led by Dr. Blechingberg Friis to evaluate the effects of remote symptom monitoring of patients with advanced lung cancer completing induction treatment in a Danish setting. Patients were randomized 1-to-1 to a remote symptom monitoring or an intervention arm added to standard care or just a standard care arm alone. Patients in the intervention arm completed an electronic questionnaire from home covering 13 common symptoms related to lung cancer. A severity alarm or threshold was applied to each question where elevated scores were sent to a clinical nurse for intervention. Weekly compliance to symptom monitoring during that first year was 82% with an intention to monitor population. Although remote monitoring did not significantly improve clinical outcomes for all patients with advanced lung cancer in the Danish population, the benefits were identified for a subgroup of patients not receiving maintenance therapy and for those with a prior organizational experience with ePROs monitoring, which may be essential for improving outcomes of symptom monitoring. In summary, as indicated by the researchers and Dr. Krzyzanowska, more research is needed using these novel approaches to determine the best ePROs platforms for the practice setting. Yet these approaches are critical to improve the overall quality of life of patients, especially during treatment, after surgery, and well into long-term survivorship. In summary, patients should be encouraged to discuss symptom burdens from physical to emotional with their oncology team and to use this technology. It was an honor and pleasure to present this research to you today. Thank you for listening to this brief summary of new research and quality care from the 2023 ASCO Annual Meeting. Best wishes. ASCO: Thank you, Dr. Hlubocky. Next, Dr. Daniel Mulrooney discusses new research on improving health equity in children, adolescents, and young adults with cancer. Dr. Mulrooney is an Associate Member in the Division of Cancer Survivorship at St. Jude Children’s Research Hospital. He is also the 2023 Cancer.Net Associate Editor for Pediatric Cancers. You can view Dr. Mulrooney’s disclosures at Cancer.Net. Dr. Mulrooney: Hello, my name is Dr. Dan Mulrooney from St. Jude Children's Research Hospital. I am the Deputy Director of the After Completion of Therapy Clinic at St. Jude and primarily care for survivors of pediatric cancers. Like previous meetings, the 2023 ASCO Annual Meeting was quite busy and full of research presentations sharing knowledge and advances in cancer treatment and care. Nearly 100 abstracts were presented concerning children with cancer, and these ranged from early studies of new agents to treat relapsed or refractory cancers, some of the most difficult to cure, to molecular profiling of tumors, to late outcome studies c

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. The theme of the 2023 ASCO Annual Meeting was “Partnering With Patients: The Cornerstone of Cancer Care and Research.” From June 2 to 6 in Chicago, Illinois, and online, cancer researchers and clinicians from around the world gathered to discuss the latest cancer research and how to ensure that all people receive the cancer care they need. In the Research Round Up series, members of the Cancer.Net Editorial Board discuss the most exciting and practice-changing research in their field presented at the meeting and explain what it means for people with cancer. In today’s episode, our guests will discuss new research in melanoma and health equity. First, Dr. Katy Tsai discusses new research in melanoma. Dr. Tsai is a medical oncologist and Assistant Professor of Medicine in the Division of Hematology and Oncology at the University of California, San Francisco. She is also the 2023 Cancer.Net Associate Editor for Melanoma & Skin Cancer. You can view Dr. Tsai’s disclosures at Cancer.Net. Dr. Tsai: Hello. Welcome to the ASCO Cancer.Net Research Round Up. I'm Katy Tsai, an associate professor of medicine and the clinical medical director of the Melanoma and Skin Cancer Program at the University of California, San Francisco. I'm happy to be here today to discuss research on melanoma and skin cancers presented at the 2023 ASCO Annual Meeting. I do not have any disclosures relevant to the studies to be discussed. So, it's always exciting to see the latest research presented at ASCO. One theme in particular that I'd like to highlight in this podcast is recent advances in the field of adjuvant therapy. For the listeners who may not be familiar with this terminology, adjuvant therapy refers to drugs given after surgery to try to decrease the risk of cancer recurrence. Specifically, late-breaking abstract 9505 presented updates from KEYNOTE-716, an adjuvant study of pembrolizumab, or pembro, in patients with resected high-risk stage II melanoma. Late-breaking abstract 9503, which I'll also discuss, presented data from KEYNOTE-942, a pivotal study of a personalized cancer vaccine plus pembrolizumab in patients with resected high-risk stage III and stage IV melanoma. So, let's start with KEYNOTE-716. We've known for some time in our field now that adjuvant pembrolizumab or nivolumab can help decrease the risk of recurrence for patients with resected stage III or IV melanoma. What may not be as well-known, however, is that patients with stage IIB or IIC melanomas, in other words, thicker, ulcerated primary melanomas, even without lymph node spread, actually have a comparable risk of melanoma recurrence compared to patients with early stage III melanomas. KEYNOTE-716 was a large, international phase 3 study that randomized patients with stages IIB and C melanoma to receive either pembro or placebo. The positive results showing improvement in relapse-free survival led to approval of adjuvant pembro in December 2021, but what was presented at ASCO was an update on distant metastasis-free survival. This is obviously an important endpoint for us because ultimately, if someone is going to develop widely metastatic disease, unfortunately, it is a development of these distant metastases that we are concerned about. So what we saw here is that with landmark 36-month follow-up, there was a 41% reduction in the risk of developing distant metastasis in patients who were treated with pembro compared to those who received the placebo. In addition, there was a consistent maintained benefit in relapse-free survival, and importantly, no changes in the side effect profile. These are important data because I believe it is practice-changing in the sense that this is a population of patients who historically might not ever have been referred to medical oncology, maybe just monitored serially with their dermatologists. And this is an option that should be discussed. Ultimately, the risk versus benefit about whether to pursue a year of therapy versus maybe consider treatment only at the time of recurrence is a very personalized discussion between a patient and their treating oncologist, but it is an option that should definitely be offered. So let's move on to KEYNOTE-942. The novel drug being tested in this trial is very exciting. We're calling it “individualized neoantigen therapy.” So this is basically a platform that allows us to develop individualized treatment for someone based on characteristics of their own cancer. This involves taking the actual tumor specimen, genomic sequencing, specifically whole-exome sequencing is performed to try to identify any changes in the DNA. And then through a bioinformatic pipeline, the mutations in the DNA that are thought to be most likely to generate proteins that can be bound within presenting molecules are then identified in the computer program, then synthesized within mRNA. So very similar to the way that COVID vaccines have been made. So this actually becomes the actual drug product. So in this study, patients were randomized to receive either pembrolizumab by itself for a year, which is, as we alluded to earlier, standard adjuvant therapy, but then with the addition of this individualized neoantigen therapy starting with dose 3 and then throughout the rest of the year. So the recurrence-free survival data were actually presented earlier this year at another major conference, AACR [American Association for Cancer Research], and were highly positive. At ASCO 2023, I think what was most impressive about the presented data is that distant metastasis-free survival, so again, a similar important endpoint that we discussed with the other trial, is that the distant metastasis-free survival here was quite impressively maintained. There was a hazard ratio of .35, meaning really a 65% reduction in the risk of recurrence for patients who received the personalized neoantigen therapy plus pembrolizumab. So this is a huge advantage for distant metastasis-free survival in this particular population of patients. What was even more intriguing is that usually when we combine therapies, we tend to see additive toxicity, more side effects. And what was really exciting about this particular trial is that the additive toxicity really wasn't as much as you would expect for giving 2 immunotherapies at the same time. I'll also highlight that even though these results are really exciting within melanoma, that part of the reason this data is so exciting is that it represents a really promising platform for therapeutic development and application in other tumors besides melanoma. So this is definitely super exciting. While perhaps not practice-changing in this moment, it’s potentially practice-changing. And I look forward to seeing additional data coming in from planned trials using this particular combination in the metastatic setting in addition to the adjuvant setting. So on the whole, I do think that updates in adjuvant therapy for melanoma were super exciting to see at ASCO 2023. As I mentioned earlier, it's a very large conference. A lot of exciting data being presented. So I do think that other themes to pay attention to as we continue to sort through existing data and look forward to incoming data from forthcoming trials is looking at neoadjuvant therapy. For example, drug given before surgery to try to improve long-term outcomes. For example, at ASCO this year, there was interesting neoadjuvant immunotherapy data presented not for melanoma, but for a different type of skin cancer called squamous cell carcinoma. So that would definitely be another theme to pay attention to in the coming months and years. Thinking about novel combinations, for example, what's new in immune checkpoint inhibitors, we've been used to for a long time referring only to anti-PD1 antibodies, anti-CTLA4 antibodies. What was interesting to see this year were updates in novel combinations, for example, PD1 antibodies combined with LAG3 antibodies. Antibodies against TIGIT. So I think this will be another exciting space to pay attention to both in the metastatic skin cancer setting and in the adjuvant and neoadjuvant settings. Thank you for your time and attention. That concludes my research roundup for melanoma and skin cancers. Thank you. ASCO: Thank you, Dr. Tsai. Next, Dr. Manali Patel discusses new research in health equity. Dr. Patel is a medical oncologist and Assistant Professor of Medicine at Stanford University. She is also the 2023 Cancer.Net Associate Editor for Health Equity. You can view Dr. Patel’s disclosures at Cancer.Net. Dr. Patel: Hi, my name is Manali Patel. I'm the Associate Editor for Health Equity for Cancer.Net, and I'm so incredibly excited to present some really amazing work that was presented at our ASCO Annual Meeting this past June in Chicago. Before I start, I do have one disclosure. I will be talking about studies that were presented relating to patient navigation and one study in particular that my group presented looking at community health workers. And so that is a little bit of a disclosure that I would like to address upfront. And now, just to get right started. I thought what was really interesting was the amount of work this year that was p

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. The theme of the 2023 ASCO Annual Meeting was “Partnering With Patients: The Cornerstone of Cancer Care and Research.” From June 2 to 6 in Chicago, Illinois, and online, cancer researchers and clinicians from around the world gathered to discuss the latest cancer research and how to ensure that all people receive the cancer care they need. In the Research Round Up series, members of the Cancer.Net Editorial Board discuss the most exciting and practice-changing research in their field presented at the meeting and explain what it means for people with cancer. In today’s episode, our guests will discuss new research in gynecologic cancers [2:06], multiple myeloma [9:15], and head and neck cancer [16:03]. First, Dr. Lan Coffman discusses new research in ovarian cancer, uterine cancer, and cervical cancer. Dr. Coffman is a physician-scientist and gynecologic oncologist at the Magee-Womens Research Institute and Foundation, and assistant professor in Hematology-Oncology at the University of Pittsburgh School of Medicine. She is also the 2023 Cancer.Net Associate Editor for Gynecologic Cancers. You can view Dr. Coffman’s disclosures at Cancer.Net. Dr. Coffman: Hi, my name is Lan Coffman. I'm a physician-scientist at the University of Pittsburgh. I'm a medical oncologist that specializes in gynecologic cancers, and I'm happy to discuss research that was presented on gynecologic cancers at the 2023 ASCO Annual Meeting. I do have a relevant disclosure. I participated in one of the trials I'm going to discuss, a trial called MIRASOL. I was the site principal investigator at University of Pittsburgh. I think there were a lot of interesting studies to highlight, and I wanted to focus on studies involving ovary cancer, endometrial cancer, and cervix cancers as the main sites that we study in the gynecologic oncology world. So when we talk about ovary cancer, I think there was one really impactful study that was presented at ASCO this year, and it was called MIRASOL. And again, this is the study that I also participated in at our hospital at University of Pittsburgh. So it was a large study, so a randomized phase 3 study looking at a drug called mirvetuximab, which is an antibody-drug conjugate. So basically, it's an antibody against a protein that is expressed on ovarian cancer cells and the protein’s called folate receptor-alpha. And that antibody basically carries a little poison. And so it's kind of like a Trojan horse. This antibody goes, finds that protein on the tumor cells, and then delivers that poison. And so this drug has been studied and actually was presented last year in a different trial called SORAYA, which showed that it had activity, meaning the drug helped to kill ovarian cancer cells, and actually led to the first approval of this drug in ovary cancer. So this trial was the confirmatory trial, so enrolling more patients to see, actually, is it better than standard-of-care chemotherapy? So this was in women with ovarian cancer that had come back and was platinum resistant, meaning the cancer started to grow within 6 months from the last platinum-based therapy. Women were eligible if they had high expression of this folate receptor-alpha, and they had to have a couple of prior lines of therapy. And then they were randomized, so kind of chosen out of a hat to either be treated with mirvetuximab or with investigator's choice chemotherapy. So one of the chemotherapies we'd use standardly. And so that would be something like taxol, or liposomal doxorubicin, or topotecan. And basically, this study was comparing how well does mirvetuximab work compared to chemotherapy. And importantly, it showed that it improved survival, both progression-free survival, so how long it took before the disease started to grow again, but probably more importantly, actually improved overall survival, so how long a woman lived. And actually changed overall survival from about 16 and a half months compared to 12 months with chemotherapy. And so this was really important and demonstrated that mirvetuximab does actually impact women with ovarian cancer and actually helps women live longer. And that's really hard to do in this setting. And the other nice thing about this trial was that not only did it work well, but there are actually lower side effects with it, and so less women actually had to discontinue their treatment, and they had less what we call adverse events, or basically bad things that had happened from the treatment themselves. So just telling us that this drug is actually well tolerated. Women feel well on it, even when their cancer is shrinking. So I think that was one of the most impactful studies in ovary cancer. Moving on to endometrial cancer. We recently had 2 studies, one called RUBY and one called GY018 that looked at using immunotherapy in combination with chemotherapy in endometrial cancer. And what was presented at ASCO was some follow-up from this RUBY trial, which was basically validating that this combination of adding immunotherapy actually helped. To give you a background, traditionally, women that have endometrial cancer that is advanced staged, meaning spread outside of the uterus itself or has come back, we treat it with chemotherapy. But this study added an immunotherapy called dostarlimab in combination with our standard chemotherapy and actually showed that women were living longer with this, at least in that progression-free survival. We're still waiting on final evaluation. But at ASCO, what they reported was another independent blinded review of the data to show that even when we're really carefully looking at this data, it looks like immunotherapy helps women with endometrial cancer live longer. They also presented quality-of-life data showing that women actually feel better with the addition of the immunotherapy. So I think this is practice changing. And again, this data has been coming out over the last year or so, but I do think this will change the way in which endometrial cancer is treated. And then the final thing I wanted to discuss would be in cervix cancer. And while there wasn't a lot of new data presented here in terms of kind of paradigm shifts or large changes, we did have final survival [data] from the KEYNOTE-826 presented, which is also using immunotherapy along with chemotherapy in cervix cancer. And so this was in women that, again, had advanced-stage cervix cancer. So it was a cervix cancer that had moved beyond the cervix itself or cervix cancer that had come back and was treated with chemotherapy along with another immunotherapy called pembrolizumab. And this was the final survival data that confirmed that the immunotherapy did help women live longer. The survival data was impressive with about a 10-month improvement in overall survival. So how long a woman lived. And so that was really confirmatory of the previous trials. So again, that emphasizes that immunotherapy is moved towards the standard of care in cervix cancer as well. I can't hit all the highlights of the impressive research coming out of ASCO 2023, this is a brief summary of some of the critical studies in gynecologic cancers. ASCO: Thank you, Dr. Coffman. Next, Dr. Sagar Lonial discusses new research in multiple myeloma. Dr. Lonial is a professor of Hematology and Medical Oncology at Winship Cancer Institute at Emory University, where he also serves as Department Chair. He is also the 2023 Cancer.Net Associate Editor for Myeloma. You can view Dr. Lonial’s disclosures at Cancer.Net. Dr. Lonial: Hello, I'm Dr. Sagar Lonial from the Emory School of Medicine and the Winship Cancer Institute in Atlanta, Georgia. And today I'm going to discuss some of the really exciting research in the context of multiple myeloma that was presented at the 2023 ASCO Annual Meeting. In terms of my conflicts of interest, I have enrolled patients on many CAR T trials as well as bispecific trials from all of the different companies involved here. So, I do have some engagement with those trials. And one of the studies that I may talk about at the end came from our institution. So I was an investigator on that study as well. When I think about some of the really exciting work that was presented at ASCO this year, there are really 2 big categories of trials that I think were most exciting. And the first is CAR T-cells and moving them earlier and earlier in the disease state. And what we saw at ASCO this year was the CARTITUDE-4 study, which was a randomized phase 3 trial comparing CAR T-cells versus standard treatment in the context of first or second relapsed multiple myeloma. And this was a really important study for us to hear because we know that CAR T-cells are highly effective in the later lines of therapy. A big question at this point is, "Does their efficacy hold up in earlier lines of therapy? And how does it compare in a randomized setting against what we might normally use in that clinical context?" And what I think we were really excited to see at ASCO this year was that CAR T-cells appear to be superior to standard treatment in the context of that randomized phase 3 trial. Now, there were a few patients who were randomized to CAR T-cells who didn't get to th

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. The theme of the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting was “Partnering With Patients: The Cornerstone of Cancer Care and Research.” From June 2 to 6 in Chicago, Illinois, and online, cancer researchers and clinicians from around the world gathered to discuss the latest cancer research and how to ensure that all people receive the cancer care they need. In the Research Round Up series, members of the Cancer.Net Editorial Board discuss the most exciting and practice-changing research in their field presented at the meeting, and explain what it means for people with cancer. In today’s episode, our guests will discuss new research in breast cancer, lymphoma, multiple myeloma, and brain tumors. First, Dr. Norah Lynn Henry discusses new research in early stage and metastatic breast cancer. Dr. Henry is Professor and Interim Chief of the University of Michigan's Division of Hematology/Oncology in the Department of Internal Medicine and the Breast Oncology Disease Lead at the Rogel Cancer Center. She is also the 2023 Cancer.Net Associate Editor for Breast Cancer. You can view Dr. Henry’s disclosures at Cancer.Net. Dr. Henry: Hi, I'm Dr. Lynn Henry, a breast cancer oncologist from the University of Michigan Rogel Cancer Center. Welcome to this quick summary of the most exciting new research in breast cancer that was presented at the 2023 ASCO Annual Meeting. I have no conflicts of interest for any of the trials that I will talk about. First, I'm going to give a very brief overview of the types of breast cancer, then talk about some research that was presented on both early-stage and metastatic breast cancer. As a reminder, there are multiple kinds of breast cancer. Some breast cancers are called hormone receptor-positive or estrogen receptor-positive and are stimulated to grow by the hormone estrogen. We treat those cancers with anti-estrogen or anti-endocrine treatments, which block estrogen or lower estrogen levels. Other breast cancers are called HER2-positive. These are often more aggressive cancers. But because they have extra copies of HER2, they often respond to treatments that block HER2. Finally, there are breast cancers that don't have hormone receptors or HER2. These are called triple-negative breast cancer and are also often aggressive cancers. Most of the results I'm going to highlight today are treatments for estrogen receptor-positive and HER2-negative breast cancer. One of the main stories from the ASCO Annual Meeting was the result of the NATALEE trial. At the present time, for patients with estrogen receptor-positive, HER2-negative early-stage breast cancer who were at high risk of having their breast cancer come back, the currently recommended treatment is anti-endocrine therapy. Based on the results of a prior trial called monarchE, we also consider adding a medicine called abemaciclib, which turns off some enzymes in the cell that are called CDK4 and CDK6, which are known to make estrogen receptor-positive breast cancer cells grow. Abemaciclib can further reduce the risk of cancer recurrence compared to endocrine therapy alone, but it does have some side effects, most commonly, diarrhea. In the NATALEE trial, which was presented for the first time at this ASCO meeting, researchers studied a similar type of medication called ribociclib. It acts similarly to abemaciclib, although it is more likely to cause low blood counts and less likely to cause diarrhea. Ribociclib is currently routinely used in combination with anti-endocrine therapy to treat patients with metastatic estrogen receptor-positive breast cancer but is not yet routinely used in the early-stage setting. In the NATALEE trial, patients with estrogen receptor-positive, HER2-negative early-stage breast cancer who are at high risk of breast cancer recurrence were enrolled. Half the patients were treated with just standard anti-endocrine therapy and half also received ribociclib for 3 years. After the 3-year treatment period, those who received both ribociclib and anti-endocrine therapy were about 25% less likely to have their cancer come back compared to those who received only anti-endocrine therapy. Overall, the medication was quite well tolerated. It is important to note that this drug is not yet FDA-approved in the setting. The remaining trials I will highlight are for treatment of metastatic breast cancer. There were many trials examining how best to use drugs that we are actually already using in the clinic. For example, many presentations were about the CDK4/6 inhibitors that I just mentioned. Typically, patients who have just been diagnosed with estrogen receptor-positive, HER2-negative metastatic breast cancer get treated with anti-endocrine therapy plus a CDK4/6 inhibitor. One trial called SONIA examined whether this is the right approach, or whether patients should just get the anti-endocrine therapy up front and hold off on starting the CDK4/6 inhibitor medication until a later time. It appears that this delayed approach would reduce symptoms as well as cost of the medication, while not reducing benefit from the treatment. Therefore, it appears it is likely fine for some patients to get just anti-endocrine therapy alone initially. However, we don't know how to identify those patients. Researchers are still figuring out which patients should follow this new treatment plan and which should keep getting the double therapy at the beginning. Some more to come in the future. There was a different trial called PADA-1 that included patients taking anti-endocrine therapy and the CDK4/6 inhibitor, palbociclib, upfront. Those patients were monitored using a blood test, looking for a mutation or a change in the estrogen receptor in the cancer. Patients who had that mutation either remained on the same treatment that they'd been on or switched to the next line of therapy, even though their scans didn't show any progression of their cancer. Overall, this switching strategy looks like a very promising approach for managing patients since it may help patients' cancer respond to treatment for a longer period of time. Although this approach is not yet officially recommended according to our guidelines. In another example, many patients with all types of metastatic breast cancer are treated with a drug called capecitabine, also known as Xeloda. Although this drug is effective for many cancers, many patients experience hand-foot syndrome, nausea, diarrhea, and mouth sores. In the X7-7 clinical trial, the researchers compared the official standard FDA-approved dose based on a patient's height and weight and given for 14 days followed by 7 days off. That was compared to a fixed dose of treatment given 7 days on and 7 days off. The trial found that the fixed-dose regimen was easier to tolerate, but importantly, the benefit from the 2 doses and schedules of treatment appears to be similar. Therefore, we will likely be using this lower dose, 7 days on and 7 days off, for most of our patients who receive treatment with capecitabine for metastatic breast cancer, since it is likely to improve their quality of life while not negatively impacting the potential benefit they receive from the therapy. There were a lot of other research findings presented that are related to treatment for both early-stage and metastatic breast cancer at the meeting. Importantly, we got glimpses of the many new drugs on the horizon for treatment of breast cancer, including a new antibody-drug conjugate against HER2, as well as other new anti-endocrine and targeted treatments. We eagerly await the results of large, randomized trials so the drugs that work can be used to treat patients with breast cancer. But for now, that's it for this quick summary of important research from the 2023 ASCO Annual Meeting. Stay tuned to Cancer.Net for future updates from upcoming breast cancer conferences. Thank you. ASCO: Thank you, Dr. Henry. Next, Dr. Christopher Flowers discusses new research in lymphomas and multiple myeloma. Dr. Flowers is the Chair of the Department of Lymphoma/Myeloma at The University of Texas MD Anderson Cancer Center and Division Head ad interim of Cancer Medicine. He is also the 2023 Cancer.Net Associate Editor for Lymphoma. You can view Dr. Flowers’ disclosures at Cancer.Net. Dr. Flowers: Hello. I'm Dr. Christopher Flowers, professor and chair of the Department of Lymphoma and Myeloma and interim division head for cancer medicine at the University of Texas MD Anderson. And it's my pleasure to talk to you today in this Cancer.Net podcast about latest updates in the hematological malignancies focused on lymphoid cancers from the American Society of Clinical Oncology Annual Meeting. The ASCO Annual Meeting every year is an exciting time for latest updates in the care of patients with cancer. And in particular this year, there were 3 abstracts that I'd like to highlight that were presentations at this meeting about lymphoid malignancies that have potential significant impact for patients over time. The first 2 come from a special session that was on late-breaking abstracts that were latest advances from clinical trials. The first is from the ZUMA-7 trial. This is a trial lo

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In September 2022, ASCO and the Society for Integrative Oncology, or SIO, published a joint guideline on using integrative therapies to manage pain in people with cancer. Integrative therapies are treatments and techniques used in addition to standard cancer treatment to help people cope with the side effects of cancer, including cancer-related pain. In this podcast, Dr. Richard Lee talks to the guideline panel co-chair, Dr. Jun Mao, about these guideline recommendations. They discuss why the guideline was created and the different types of integrative therapies included in these recommendations, including acupuncture, reflexology and acupressure, hypnosis, massage, yoga, guided imagery and progressive muscle relaxation, and music therapy. Dr. Lee is a clinical professor in the Departments of Supportive Care Medicine and Medical Oncology at City of Hope Comprehensive Cancer Center and serves as the medical director of the Integrative Medicine Program. Dr. Lee is also the 2023 Cancer.Net Associate Editor for Palliative Care. Dr. Mao is chief of the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center and holds the Laurance S. Rockefeller Chair in Integrative Medicine at the institution. View disclosures for Dr. Lee and Dr. Mao at Cancer.Net. Dr. Lee: My name is Richard Lee. I'm a clinical professor here at City of Hope Cancer Center. I'm in the Departments of Supportive Care Medicine and Medical Oncology and medical director for the Integrative Medicine Program. I'm honored to be accompanied today by Dr. Jun Mao. He's the chief of the Integrative Medicine Service at Memorial Sloan Kettering and holds the Laurance S. Rockefeller Chair in Integrative Medicine. So we're going to talk about the joint SIO-ASCO guidelines that recently came out in the Journal of Clinical Oncology looking at integrative approaches to cancer pain. And so let me first ask you, Jun, could you talk about what is a clinical practice guideline, and how does it help guide cancer care? Dr. Mao: The clinical practice guideline is a process bringing multidisciplinary experts to look at the evidence from randomized clinical trials or systematic reviews and meta-analysis and to really evaluate the level of the evidence from research and clinical trials, and also incorporate our clinical expertise, consideration for the benefit and risk. Then, making a set of recommendations for doctors and nurses, health care providers to make informed decisions for patients. Dr. Lee: Great. And tell us more, what is integrative medicine for those patients who may not have a full understanding what this field is about? Jun Mao: So integrative medicine is a complex term. Originally, a lot of people may have heard that term of “alternative medicine” or “complementary medicine.” So those terms are referring to using things like herbs or shamanism instead of a conventional cancer treatment. So recognizing the needs of patients who want to explore alternative ways to help them to cope with cancer, and the importance of adhering to conventional surgery, radiation therapy, chemotherapy. So the field of integrative medicine has emerged. Integrative medicine is a field that is based on evidence and acknowledge the patient's wishes to carefully incorporate evidence-based lifestyle interventions, mind-body treatments, and consider for natural products and herbal medicine in a safe and effective way to improve patients' physical, emotional, and spiritual well-being. Also, part of the goal of integrative medicine is to really engage the patient as an active participant to prevent cancer and to really engage in their own care during and beyond their cancer treatment. Dr. Lee: And for patients who are new to this concept of integrative medicine or integrative therapies, why is it important for us to study this for cancer care? Dr. Mao: Richard, this is really important because often when a person gets cancer, you get friends and family who really want to be helpful who say, “Do this, try that, use this herb, or this supplement has been used by that.” So there's a lot of anecdote. There's a lot of sort of people just want to be helpful. But in actuality, some of the treatments, without carefully considering actual evidence and potential risks of drug herbal interaction, can induce harm, not only increase the toxicity of the cancer treatment, but may even shorten the lives of cancer patients. Therefore, we often tell patients don't use these treatments as alternative, but to use in an integrated way. And doing research is going to be helpful to understand in what setting for what condition or symptoms. These are helpful, not helpful, are they safe or unsafe? Dr. Lee: That's really important. That's great to see the research coming along. And so let's talk about ASCO, the American Society for Clinical Oncology, which is the world's leading and largest professional organization for oncologists, as well as Society for Integrative Oncology, SIO. You know, how did they come together to produce this joint guideline on integrative medicine and pain management? Dr. Mao: So, as you know, ASCO is a world-leading conventional oncology society. It's a multi-discipline, you know, surgeons, medical oncologists, radiation oncologists, a lot of psychosocial supportive care folks are part of this society. Society for Integrative Oncology is a relatively new society, but this year we're celebrating 20th year, so it's not so new anymore. You know, a lot of very passionate physicians, nurses, nutritionists, social workers, we joined together to really help to advocate for evidence-based integrative medicine in the context of care delivery. SIO brings that expertise together with ASCO to formulate a set of guidelines that can be readily implemented into the care setting to help patients and families to deal with pain, a very common and disturbing side effect for cancer and cancer treatment. Dr. Lee: It's so great to see 2 leading organizations come together to put these guidelines together. So let's jump into the guidelines a little bit, and one of the areas that they covered is acupuncture. So can you let us know and let patients know what is acupuncture, and what types of cancer-related pain has it been shown to be helpful? Dr. Mao: Acupuncture is a type of therapy that originated from the traditional Chinese medicine. It has been documented over 2,500 years ago. So the way acupuncture works clinically is putting very thin, sterile needles in specific locations of the body to help address symptoms, promote a sense of relaxation and wellness. Often, you need a series between 6 to 10 treatments. I always tell patients it's almost like a physical therapy. You need a few treatments to see the benefit. In animal research, there has been a documented mechanism that acupuncture may help your brain to release endogenous neurotransmitters, like endogenous opiates, serotonin, or dopamine, as a result to reduce pain, increase a sense of relaxation, well-being. So the ASCO-SIO Joint Clinical Guideline looked at clinical trials, found pretty strong evidence that acupuncture can be used for a type of joint pain that is very common in women with breast cancer taking aromatase inhibitors. Aromatase inhibitors are a class of drug that drop the estrogen level in women with breast cancer as a result of preventing the breast cancer from spreading. Unfortunately, about 50% of women do develop very diffuse joint pain. A lot of time it is in the low back and knees and makes a lot of patients stop this life-saving drug. The committee feels strongly like acupuncture should be recommended as one of the options to treat aromatase inhibitor-related joint pain. In other areas, not as strong, but also in general cancer-related joint pain and musculoskeletal pain. And there are also some weak evidence on acupuncture can be helpful for chemotherapy-induced peripheral neuropathy, as well as to be used in post-surgical related pain. So those are the recommendations we would tell a patient who experienced those pains to try acupuncture. Dr. Lee: So Jun, you mentioned about the different recommendations around acupuncture, and you're talking a little bit about levels of evidence. Could you explain to patients what you mean by the levels of evidence and the types of recommendations that were put forward by ASCO and SIO? Dr. Mao: So when experts review evidence from clinical trials, if you have several large clinical trials producing very consistent findings that a therapy is beneficial with very low risk, that will give you a high level, strong quality of evidence with strong recommendation. Unfortunately, in the field of integrative medicine, often there's a lack of funding for this type of research. So what you do see is there are maybe only 1 trial showing that it's very beneficial and maybe there are some smaller trials to show some signal, then we will give an intermediate quality of evidence and moderate strength of recommendation. And then you have therapies that are being used by patients, but there's very little trials or the trials, the sample size are very small. Sample size means how many patients participate. Then you see some prom

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. Fatigue is a common symptom of cancer and its treatment, and it can be very difficult to treat. However, exercise is one simple method that’s been shown to help people with cancer manage and cope with cancer-related fatigue. In this podcast, Dr. Anna Roshal talks with Dr. Tarah Ballinger and exercise physiologist Danielle Halsey about what people with cancer should know about cancer-related fatigue and the ways that exercise can help. Dr. Roshal is a medical oncologist and assistant professor of clinical medicine at the Indiana University School of Medicine. She is also a member of the Cancer.Net Editorial Board. Dr. Ballinger is a medical oncologist, an assistant professor of clinical medicine, and the Vera Bradley Foundation Scholar in Breast Cancer Research at the Indiana University School of Medicine. Ms. Halsey is the lead exercise physiologist at the Indiana University Melvin and Bren Simon Comprehensive Cancer Center. You can view disclosures for Dr. Roshal, Dr. Ballinger, and Ms. Halsey at Cancer.Net. Dr. Anna Roshal: Hello, my name is Dr. Anna Roshal. I am a medical oncologist at Indiana University, and I am very, very pleased to have 2 great guests today, Dr. Tarah Ballinger and Danielle Halsey, who is an exercise physiologist. And the topic of our podcast today is cancer fatigue. So before we start, I'm just going to disclose that none of us have any relevant conflicts to disclose today. So I will introduce our guests very briefly. So Dr. Ballinger is also a medical oncologist here at Indiana University. She is an assistant professor of medicine and also an associate director of our supportive oncology program. And like I said, Danielle Halsey is the lead exercise physiologist supporting our Multidisciplinary Oncology Vitality and Exercise (MOVE) program for patients with cancer. So my first question to start us, and I would direct to Dr. Ballinger, but Danielle, please jump in as well. We all know that cancer patients have a lot of fatigue, and there's many, many reasons why. And it's actually one of the most common, if not the most common concern and complaint that our cancer patients have as they're first diagnosed and as they're going through treatment, and also even after treatment. So it is something that specifically affects their quality of life, maybe more than any other symptoms. So, Dr. Ballinger, can you discuss what are some of the reasons cancer itself and cancer treatments can cause fatigue? Dr. Tarah Ballinger: Yeah, that's a great and somewhat difficult question. So as you mentioned, cancer-related fatigue is the most prevalent cancer-related symptom, both in patients going through treatment, but even for many years after experiencing cancer. Cancer patients have significantly more fatigue than someone who has not gone through the disease. The reason why it's so prevalent and so difficult to treat is because the causes of it are so multifactorial. There's, of course, physical symptoms from cancer that can cause fatigue, pain, shortness of breath, depending on where the cancer might be located. And there are psychological symptoms associated with cancer that can cause fatigue, like anxiety, depression. Definitely trouble sleeping is a big issue. But even beyond these symptoms from cancer, tumors themselves have direct effects that can cause fatigue. So cancer itself causes inflammation that can impact hormone production and other balances in the body that can certainly cause fatigue. And all of that is before we even start to talk about the other thing you mentioned, which is side effects of treatment. So that includes anemia, which means there's less red blood cells, so there's less oxygen delivery to tissues, and that can make people feel a lot more tired. We also have a lot of evidence that cancer treatments actually impact muscle function at the cellular level. Often what I hear from patients is that they feel sore, like they've worked out, but they haven't actually done anything. And that's really a real thing directly caused by cancer and its treatments. So again, the reason this is so hard to treat is because there are so many potential things that are kind of coming together to cause the problem. Dr. Anna Roshal: Yeah, that's certainly very interesting. And again, it's complex and lots and lots of factors contributing. I'm curious to hear how would you distinguish, we've all been tired, right? So there's regular tiredness and there is this relentless cancer fatigue that our patients experience. And it's, how do we tell the difference and how do our patients tell the difference? That's most important. How do your loved ones tell the difference of somebody just having a difficult day and they’re tired, or is this cancer fatigue that we're talking about? Dr. Tarah Ballinger: Yeah, cancer-related fatigue is different from the fatigue I might have if I stayed up late or was in clinic all day. That fatigue you can push through and probably will get better if you take a nap. Cancer-related fatigue, classically, it somewhat feels like moving through sand, like you just can't get through it. Taking a nap tends to not be something that actually makes it better. And I think that can be a real struggle for patients in terms of their loved ones relating to them because a lot of people will think, oh, well just get some rest and you'll feel better. But that's not really how it works for cancer-related fatigue, which is why we try to look for other ways to try to improve this symptom. Dr. Anna Roshal: That's a great point. I certainly noticed that in my patients and certainly noticed it in my interactions with the loved ones of patients because that's one of the most common responses. So they just didn't get enough sleep or maybe they didn't drink enough water or anything like that. But we do know that it's much more complex than that. So maybe this is a good jumping point to talk about what kind of research has been done to look into how we can make this better. You know, since fatigue is this very complex symptom affecting our patients’ quality of life, what can we do to make this better? Dr. Tarah Ballinger: Yeah, so that's one of the reasons I'm really excited that we're talking about this prevalent symptom today because one of the, or the best thing that we have found to help with cancer-related fatigue is actually exercise. And that can seem a little bit counterintuitive if you're fatigued that you should exercise, but even light movement can help. So what's really awesome about exercise is that it can target all of those different mechanisms for cancer-related fatigue that I mentioned. And that's really different from what we typically think of in treatment, which is medications. Medications have kind of 1 mechanism of action. They might treat 1 cause of something, but exercise is able to actually treat all those different potential causes of cancer-related fatigue. So it can help with physical symptoms from the cancer, the psychological symptoms from the cancer, and even those direct effects of the tumor and the treatment. So exercise, it's really one of the only things that's been proven to improve the symptoms of cancer-related fatigue. It helps with our muscle function. It helps improve oxygen delivery to tissues. And when you exercise, it actually changes your body's immune system and it's anti-inflammatory. So there are true scientific mechanistic reasons for why exercise can be helpful. And again, it's one of the only things that we've proven over and over again can and does improve these symptoms. Dr. Anna Roshal: That's great. And that's, yeah, like you said, it does seem counterintuitive. And I find that as an oncologist discussing this with patients in the clinic can be quite challenging. Because like, yeah, I'm tired. And you really want me to do what? So yeah. So maybe this would be a great point for Danielle to jump in and talk about what kind of exercise, right? Because when we talk exercise, there are so many different ways people can exercise and do exercise. So what kind of exercise? Is this walking? Is this weights? And can we talk about, maybe in detail, of what kind of exercise has been looked at and found beneficial or what you recommend for patients? Danielle Halsey: Yeah, of course. So exercise walking and resistance training have both been proven in lots of research that it is beneficial to patients and their cancer-related fatigue, but also in combination. And one of the big things that I talked to you about with patients is just finding the exercise that works best for them and something that they're going to stick to. And so the actual “dosage,” and I say that with air quotes as I say it, but what the research has shown or what strong evidence has shown is that at least 3 times a week of some sort of aerobic activity, so that can be swimming, walking, if you like running, running, if it's biking, some sort of aerobic activity at a moderate intensity that will get your heart rate up for 30 minutes, has been linked to a decrease in cancer-related fatigue. And then at least 2 days a week of resistance training for at least 2 sets at 12 to 15 reps is going to have a positive impact on ca

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. Brielle Collins: Hi everyone, I'm Brielle Gregory Collins, a member of the Cancer.Net content team, and I'll be your host for today's Cancer.Net podcast. Cancer.Net is the patient information website of ASCO, the American Society of Clinical Oncology. June 15th to June 21st, 2023, marks the third annual National Black Family Cancer Awareness Week, an initiative led by the U.S. Food and Drug Administration's, or FDA's, Oncology Center of Excellence to increase cancer awareness within the Black community. Today we're going to be talking about cancer disparities in the Black community, the importance of cancer screening and prevention for Black families, and resources available to Black families for support. Our guests today are Dr. Luckson Mathieu and Rea Blakey. Dr. Mathieu is a thoracic oncologist at the FDA in the Division of Oncology 2. Thanks for joining us today, Dr. Mathieu. Dr. Luckson Mathieu: Happy to be here. Thank you for inviting me. Brielle Collins: Ms. Blakey is the Associate Director for External Outreach and Engagement at the Oncology Center of Excellence and leads the National Black Family Cancer Awareness Initiative for the Oncology Center of Excellence Project Community. Thanks for joining us today, Ms. Blakey. Rea Blakey: Thank you, happy to be here. Brielle Collins: Before we begin, we should mention that Dr. Mathieu and Ms. Blakey do not have any relationships to disclose related to this podcast, but you can find their full disclosure statements on Cancer.Net. Now to begin, Dr. Mathieu, research has shown that Black people are more adversely affected by cancer than other racial and ethnic groups in the U.S. Can you describe some of the cancer disparities that exist in the Black community? Luckson Mathieu: Sure, thank you for that question. Before providing a description, I would like to first define cancer health disparities. The National Cancer Institute, or the NCI, defines cancer health disparities as adverse differences that exist among certain population groups and cancer measures, such as numbers of cases, the number of deaths, cancer-related health complications, and quality of life after cancer treatment. Black and African American people have higher rates of acquiring and dying from cancer compared to members of other races. For many of the most common types of cancer, including breast, lung, prostate, and colorectal, the incidence and deaths are higher among African Americans than any other racial and ethnic groups. Furthermore, despite having similar rates of breast cancer, African American women are more likely than White women to die of this disease. African American men have a prostate cancer death rate more than double than that of men of other racial groups. Unfortunately, my description is a brief depiction of an alarming and expansive reality. Brielle Collins: Thank you for walking through that, Dr. Mathieu. And thank you, too, for providing that definition of disparities. And Ms. Blakey, can you describe the purpose of National Black Family Cancer Awareness Week and its role in addressing these disparities and raising cancer awareness in the Black community? Rea Blakey: Sure, happy to. The purpose of the National Black Family Cancer Awareness initiative and the dedicated social media week is to increase cancer awareness in one of the most vulnerable segments of the U.S. population, as you just heard described. OCE's Project Community appreciates ASCO's Cancer.Net involvement, absolutely. We also aim to marshal community-based stakeholders, faith-based organizations, historically Black colleges and universities, Black sororities and fraternities, all of this to increase cancer awareness and to build knowledge surrounding cancer clinical trial participation, as well as minority population donations to national genetic databases for cancer research. So OCE's Project Community is the hub of the social media campaign for the National Black Family Cancer Awareness Week via our hashtag, #BlackFamCan. Project Community's intent is to enlist and encourage a wide array of public and private community-focused engagement entities, organizations, families even, throughout the U.S. and beyond, to support efforts to increase cancer clinical trial awareness. So with a common and concerted mission, organizers are urged to focus their supportive endeavors and activities to occur during National Black Family Cancer Awareness Week. That's also in conjunction with the White House Cancer Moonshot Goals. Brielle Collins: Wonderful, and it sounds like that hashtag, #BlackFamCan, is a good place for people to go if they want to learn more as the week progresses. Rea Blakey: Absolutely. Brielle Collins: Wonderful. And Ms. Blakey, what do you think is most important for Black families to know about their cancer risk? Rea Blakey: The hashtag, #BlackFamCan, and there's also a tagline that's called “Engaging the Generations.” So we know African Americans have the highest mortality rate of any racial and ethnic groups for all cancers combined and for most major cancers. That contributes to a lower life expectancy, obviously, for African American men and women. And so with that, the real effort here is to get people to talk to their families. All too often, families don't really know their own cancer history, and some find it just too difficult to talk about, especially with older generations who may have associated a stigma with a cancer diagnosis, or those who just don't tell to avoid being perceived as a burden to others in their family. So engaging the generations is one of the key aspects of personal or familial cancer awareness and understanding risk and mapping out preventive strategies and pursuing cancer screening. Not only does it take a village, but it requires every generation. Brielle Collins: Absolutely. And I want to build on that piece of cancer screening. So Dr. Mathieu, can you talk a little bit about why cancer screening is so important and some of the hurdles that Black families may face in getting regular screening? Luckson Mathieu: Yeah, absolutely. So cancer screening tests, such as Pap smears, mammogram, low-dose CT scans, and colonoscopy, can help find cancer at an early stage before symptoms appear. When abnormal tissue and cancer is found early, it may be the best time or the more easier time to treat. And treatment may even result in cure. By the time symptoms appear, cancers may have grown and spread, thereby making it more challenging to treat and/or cure. Black people are at the highest risk for cancer deaths. This increased mortality risk may reflect a later stage disease at the time of diagnosis among Black patients. Cancer screening is so important for everyone, especially Black people, because it helps identify cancer early and thereby allows for better clinical outcomes. Regarding the hurdles for cancer screening, I believe the hurdles varies for each family. There may be many complex and interrelated factors that can stand in the way of screening for Black families. Each family should directly address that question of what is in the way of getting appropriate screening for cancer. Identifying and overcoming the hurdles may be the best way to address this cancer screening disparity. Brielle Collins: Got it. Thank you for walking through that. And in terms of resources, Dr. Mathieu, what resources are available to help Black people access this screening? Luckson Mathieu: So your primary care physician can serve as a good start to discover cancer screening resources. Earlier this year, the Department of Health and Human Services announced the Accelerating Cancer Screening Program. The program's goal is to accelerate access to cancer screening as part of the Cancer Moonshot Initiative. I would encourage everyone to go online and consider the role a local HRSA-supported health center can play in the process of getting screened for cancer. In addition, NCCN.org, CDC.gov, American Cancer Society, and the FDA are great online resources to obtain more information on cancer screening. Brielle Collins: Perfect. And I really want to talk about that cancer prevention piece, too, which is another incredibly important element of this. So why is cancer prevention in particular so important, and what measures can Black families take to prevent cancer? Luckson Mathieu: Yeah, cancer prevention is important because the best treatment for cancer is to prevent it from occurring at all or catch it at the earliest and most curable stage. In addition, cancer prevention offers the most cost-effective long-term strategy to manage cancer’s devastating societal impact. As previously mentioned, screening tests can find cancers early when they are treatable and it has the prospect of cure. In addition to regular screening tests, everyday behaviors such as not smoking cigarettes, maintaining a healthy weight, and being vaccinated against certain cancer-causing viruses can all help prevent cancer from developing. Brielle Collins: Thank you. And Ms. Blakey, going back to some resources, what resources are available to help Black families as they navigate cancer screening and prevention? Rea Blakey: Well, I'll start with the p

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In this podcast, Cancer.Net Specialty Editor Dr. Petros Grivas talks to Dr. Marianne Dubard-Gault about what people with bladder cancer should know about genetics and genetic testing, including what information genetic testing can provide, how it can inform bladder cancer treatment, and what to expect when meeting with a genetic counselor. Dr. Grivas is a medical oncologist at Seattle Cancer Care Alliance, clinical director of the Genitourinary Cancers Program, and professor at the University of Washington School of Medicine. He is also an associate member of the Clinical Research Division at Fred Hutchinson Cancer Research Center. Dr. Dubard-Gault is the medical director of the Cancer Genetics Program at Fred Hutchinson Cancer Research Center and an assistant professor at the University of Washington School of Medicine.   View disclosures for Dr. Grivas and Dr. Dubard-Gault at Cancer.Net. Dr. Grivas: Hello, I'm Dr. Petros Grivas. I'm a medical oncologist and serving as the clinical director of the Genitourinary Cancers Program and professor at the University of Washington Fred Hutchinson Cancer Center. I'm very excited and thrilled today to discuss with one of the amazing leaders in the field of cancer genetics, Dr. Marianne Dubard-Gault, who is my colleague here at UW Fred Hutchinson and has been such a wonderful human being and advocate for her patients and also really a key opinion leader in the field of genetics and the implementation in patient care. Dr. Dubard-Gault, welcome, and I will let you introduce yourself. Dr. Dubard-Gault: Thank you very much, Dr. Grivas, and it's a pleasure to be here. So thank you for the invitation. I am Dr. Marianne Dubard-Gault. I am a trained oncology doctor and a trained genetics doctor, and my focus now, as Dr. Grivas mentioned, is in the cancer genetics world where I help people either get genetic testing in the first place and/or their family members have interventions for their screening and early detection. I'm also an assistant professor at Fred Hutchinson Cancer Center in Seattle, Washington, and then at the University of Washington on the other side. And I lead the Cancer Genetic Survey Center at Fred Hutchinson Cancer Center. And I have no disclosures. Dr. Grivas: Thank you so much, Marianne, and again, thank you for helping our patients. And I'm really, really excited today because it's a very important topic, not frequently discussed. And I really, really wanted to make this happen, and thanks to Cancer.Net for helping us getting the word out there. I have no relevant disclosures in this topic. My disclosures are listed on the ASCO website. And Marianne, I will start us off by asking you, just for the audience to set the stage, can you define what we call “genetics”? What exactly are we referring to? Dr. Dubard-Gault: Yes, that's actually very important. That's probably the first thing that happens in the clinic when we talk to patients is, what is genetics anyway, right? So genetics is the study of the DNA or the genetic makeup that we all have. And that makes a person who they are, right? So looking into the genetic makeup to make sense of it and inform treatment or other interventions. Dr. Grivas: Thank you much, Marianne. And I think it's so important again for our patients to understand the definitions here. So let me ask you, can you define the difference between a genetic mutation versus genetic alteration? How would you explain that to a patient? Dr. Dubard-Gault: I think about them in a similar way. So, to me, a genetic mutation or alteration is a spot in your DNA. So there's a long stretch of letters, and there's a spot in there that either was copied or wasn't copied properly over. And so that leads to a command that kind of not being executed properly. And so an example of that would be if I gave you the 2 words “red” and “bed,” those 2 words would mean totally different things in your mind. And so if you were supposed to hear “red” and you heard “bed,” then downstream will be a different outcome. Dr. Grivas: Thank you so much, Marianne. And this is very important because for the audience as you pointed out nicely, the genetic code, the DNA translates a message, alright, that becomes a protein and eventually a function of the cell. So if that code, if that message is misspelled, it can lead to different altered and changed-up protein for the cell. That has implications and can potentially predispose someone to cancer. So if we can also help the audience understanding the differences between what we call “somatic genetic mutations” and “germline mutations.” Dr. Dubard-Gault: Absolutely. And this is also something that comes up every time because they're part of the same groups of things overall, right? So somatic means tissue or tumor. And germline, or hereditary, sometimes you'll hear that word interchangeably means inherited or hereditary or part of the genetic makeup or the code that you were born with. So different parts of our body have different genetic mutations. And that is why even with 2 identical twins, they won't have the same moles on their skin, or they won't have the same medical conditions, even if they have exactly the same genetic code. And it's exactly the same for a person who has a tumor, right? The DNA or the genetic makeup they were born with will stay exactly the same as they grow older, but the genetic makeup their tumor has as the tumor grows can change and make more or have more mutations. So testing different parts of the body will help tease out which ones of the mutations are located where? Is it in a tumor only? Is it in the genetic makeup you were born with or is it part of that transition between the 2? Dr. Grivas: Thank you, Marianne. I think this is great when we explain to the patients what exactly mutations, alterations, means, and the difference between a somatic tumor testing, as you said, mostly to help define treatment options. And what you very nicely discussed are germline testing, looking at hereditary predisposition to cancer that can impact the patient and also family members and the broader family. And one kind of take-home message may be for our audiences, when someone is about to see an oncologist or their provider, is greatly helpful if they can do quote-unquote "their homework" and try to understand and delineate and capture as much as possible regarding the family history. And sometimes it's hard, especially when you go to distant relatives, cousins, nephew, nieces, it's more difficult, but it can help a lot and inform that discussion and whether a referral to a genetic counselor or geneticist is relevant. So that's what we try to do with nurse navigation these days to help inform people with cancer before their appointment how they can maximize to capture that information, it can be helpful to them and for the provider. And the next question, Marianne, is how common are these genetic germline mutations in people with bladder cancer? Dr. Dubard-Gault: I think the answer is still out there. We don't have the complete answer today. We don't know all the genes that are implicated in bladder cancer today. So given that, we probably don't have the full or complete answer as to how many people with bladder cancer would have it. But kind of to get close to the answer, as close as we can possibly be today, I think it depends on the group of patients with bladder cancer that you test, but I would probably give a 1 in 10 people with bladder cancer would have an inherited genetic mutation. Dr. Grivas: And that's very helpful Marianne. And of course, varies, of course, across the different scenarios and the family history as you mentioned, the age of cancer diagnosis. And sometimes it's interesting in patients with urothelial carcinoma, cancer in the upper urinary tract, like renal pelvis, kidney problems, or ureter, there seems to be some higher frequency of germline mutations in that as opposed to bladder cancer. Of course, it can happen in that scenario, but seems to be some higher frequency in the upper tract cases, is that right? Dr. Dubard-Gault: I agree. Not all cancers are created equal, right? In the bladder, that's probably also true. So depending on where it starts, the type of cells that are involved, and how the person was born with certain genetic predispositions, it may very well affect how all of these are linked together in one line of event versus maybe something that happened randomly or occurred that we don't have a one specific answer or a combination of answers. Dr. Grivas: That's a great point. And obviously, there are the huge impacts that we discussed to help prevent cancers in the bladder family. Cancer prevention mode, I call it, when I explain to the patients before they see you. And also, some patients are also asking, in addition to that family benefit in my brother’s family, is there any potential impact on the treatment selection for the bladder cancer? Any comment? Dr. Dubard-Gault: Yes, I do believe there is actually more today than ever before, especially with the new medications that have come around, right? So sometimes a genetic mutation will happen in the DNA or the code that is impor