ASCO Education

Dr. Pedro Barata and Dr. Rana McKay discuss the integration of innovative advances in molecular imaging and therapeutics to personalize treatment for patients with renal cell and urothelial carcinomas. TRANSCRIPT Dr. Pedro Barata: Hello, I'm Dr. Pedro Barata, your guest host of By the Book, a podcast series featuring insightful conversations between authors and editors of the ASCO Educational Book. I'm a medical oncologist at University Hospitals Seidman Cancer Center and an associate professor of medicine at Case Western Reserve University in Cleveland, Ohio. I'm also an associate editor of the ASCO Educational Book. Now, we all know the field of genitourinary cancers (GU) is evolving quite rapidly, and we have new innovations in molecular imaging as well as targeted therapeutics. Today's episode will be exploring novel approaches that are transforming the management of renal cell and urothelial carcinomas and also their potential to offer a more personalized treatment to patients. For that, joining for today's discussion is Dr. Rana McKay, a GU medical oncologist and professor at University of California San Diego. Dr. McKay will discuss her recently published article titled, “Emerging Paradigms in Genitourinary Cancers: Integrating Molecular Imaging, Hypoxia-Inducible Factor-Targeted Therapies, and Antibody-Drug Conjugates in Renal Cell and Urothelial Carcinomas.”  Our full disclosures are available in the transcript of this episode.  And with that, Rana McKay, great to have you on the podcast today. Dr. Rana McKay: Oh, thank you so much, Dr. Barata. It's really wonderful to be here with you. So, thanks for hosting. Dr. Pedro Barata: No, thanks for taking the time, and I'm looking forward to this conversation. And by the way, let me start by saying congrats on a great article in the Educational Book. Really super helpful paper. I'm recommending it to a lot of the residents and fellows at my own institution. I would like to first ask you to kind of give our listeners some context of how novel approaches in the molecular imaging as well as targeted therapeutics are actually changing the way we're managing patients with GU, but specifically with renal cell carcinoma and urothelial carcinoma. So, what are the areas you would call out as like being big areas for innovation in this context, and why are they important? Dr. Rana McKay: Very good question. And I think this is really what this article highlights. It highlights where are we going from an imaging diagnostics standpoint? Where are we going from a therapeutic standpoint? And I think if we have to step back, from the standpoint of diagnostics, we've seen PET imaging really transform diagnostics in prostate cancer with the advent of PSMA PET imaging, and now PSMA PET imaging is used as a biomarker for selection for theranostics therapy. And so, we're starting to see that enter into the RCC landscape, enter into the urothelial cancer landscape to a lesser extent. And I think it's going to potentially be transformative as these tools get more refined. I think when we think about therapeutics, what's been transformative most recently in the renal cell carcinoma landscape has been the advent of HIF2α inhibition to improve outcomes for patients. And we have seen the approval of belzutifan most recently that has reshaped the landscape. And now there's other HIF2α inhibitors that are being developed that are going to be further important as they get refined. And lastly, I think when we think about urothelial carcinoma, the greatest transformation to treatment in that context has been the displacement of cisplatin and platinum-based chemotherapy as a frontline standard with the combination of enfortumab vedotin plus pembrolizumab. And we've seen antibody-drug conjugates really reshape treatment and tremendously improve outcomes for patients. So, I think those are the three key areas of interest. Dr. Pedro Barata: So with that, let's focus first on the imaging and then we’ll get to the therapeutic area. So, we know there's been a paradigm shift, really, when prostate-specific targets emerged as tracers for PET scanning. And so, we now commonly use prostate-specific membrane antigen, or PSMA-based PET scanning, and really transform how we manage prostate cancer. Now, it appears that we're kind of seeing a similar wave in renal cell carcinoma with the new radiotracer against the target carbonic anhydrase IX. What can you tell us about this? And is this going to be available to us anytime soon? And how do you think that might potentially change the way we're managing patients with RCC today? Dr. Rana McKay: First, I'll step back and say that in the context of PSMA PET imaging, we have actually been able to better understand RCC as well. So, we know that PSMA is expressed in the neovasculature of tumors, and it can actually be used to detect renal cell carcinoma tumors. It has a detection rate of about 84% when used for detection. And so, you know, I don't think it's just restricted to carbonic anhydrase IX, but we will talk about that. So, PSMA expressed in the neovasculature has a detection rate of around 84%, particularly if we're looking at clear cell RCC. CAlX is overexpressed in clear cell RCC, and it's actually used in diagnosing renal cell carcinoma when we think of CAlX IHC for diagnosing clear cell RCC. And now there are CAlX PET tracers. The first foray was with the ZIRCON study that was actually an interestingly designed study because it was designed to detect the likelihood of PET imaging to identify clear cell RCC. So, it was actually used in the early diagnostics setting when somebody presents with a renal mass to discriminate that renal mass from a clear cell versus a non-clear cell, and it was a positive study. But when I think about the potential application for these agents, you know, I think about the entire landscape of renal cell carcinoma. This is a disease that we do treat with metastasis-directed therapy. We have certainly seen patients who've undergone metastasectomy have long, durable remissions from such an approach. And I think if we can detect very early onset oligometastatic disease where a metastasis-directed therapy or SABR could be introduced - obviously tested in a trial to demonstrate its efficacy - I think it could potentially be transformative. Dr. Pedro Barata: Wonderful. It's a great summary, and I should highlight you are involved in some of those ongoing studies testing the performance of this specific PET scanning for RCC against conventional imaging, right? And to remind the listeners, thus far, for the most part, we don't really do FDG-PET for RCC. There are some specific cases we do, but in general, they're not a standard scanning. But maybe that will change in the future. Maybe RCC will have their own PSMA-PET. And to your point, there's also emerging data about the role of PSMA-PET scanning in RCC as well, as you very elegantly summarized. Wonderful. So, let me shift gears a little bit because you did, in your introduction, you did highlight a novel MOA that we have in renal cell carcinoma, approved for use, initially for VHL disease, and after that for sporadic clear cell renal cell carcinoma. We're talking about hypoxia-inducible factor 2-alpha inhibitors, or HIF2α inhibitors, such as belzutifan. But there's also others coming up. So, as a way to kind of summarize that, what can you tell us about this breakthrough in terms of therapeutic class, this MOA that got to our toolbox of options for patients with advanced RCC? Tell us a little bit what is being utilized currently in the management of advanced RCC. And where do you see the future going, as far as, is it moving early on? Is it getting monotherapy versus combinations? Maybe other therapies? What are your thoughts about that? What can you tell us about it? Dr. Rana McKay: Belzutifan is a first-in-class HIF2α inhibitor that really established clinical validation for HIF2α as a therapeutic target. When we think about the activity of this agent, the pivotal LITESPARK-005 trial really led to the approval of belzutifan in patients who were really heavily pretreated. It was patients who had received prior IO therapy, patients who had received prior VEGF-targeted therapy. And in the context of this study, we saw a median PFS of 5.6 months, and there did seem to be a tail on the curve when you looked at the 12-month PFS rate with belzutifan. It was 33.7% compared to 17.6% with everolimus. And then when we look at the response rate, it was higher with belzutifan on the order of 22-23%, and very low with everolimus, as we've previously seen. I think one of the Achilles heels of this regimen is the primary PD rate, which was 34% when used in later line. There are multiple studies that are testing belzutifan in combination across the treatment landscape. So, we have LITESPARK-011, which is looking at the combination of belzutifan plus lenvatinib in the second-line setting. We've got the MK-012 [LITESPARK-012] study, which is looking at belzutifan in various combinations in the frontline setting. So there is a combination with IO plus belzutifan. And so this is also being looked at in that context. And then we also have the LITESPARK-022 study, which is looking at pembrolizumab with belzutifan in the adjuvant setting. So there's a series of studies that will be exploring belzutifan really across the treatment landscape. Many of these studies in combination. Additionally, there are other HIF2α inhibitors that are being developed. We have casdatifan, which is another very potent HIF2α inhibitor. You know, I think pharmacologically, these are different agents. There's a different half-life, different dosing. What is going to be the recommended phase 3 dose for both agents, the EPO suppression levels, the degree of EPO suppression, and sustainability of EPO suppression is very different. So, I think we've seen data from casdatifan from the ARC-20 trial from monotherapy with a res

Dr. Hope Rugo and Dr. Kamaria Lee discuss the prevalence of financial toxicity in cancer care in the United States and globally, focusing on breast cancer, and highlight key interventions to mitigate financial hardship. TRANSCRIPT  Dr. Hope Rugo: Hello, and welcome to By the Book, a podcast series from ASCO that features engaging conversations between editors and authors of the ASCO Educational Book. I'm your host, Dr. Hope Rugo. I'm the director of the Women's Cancer Program and division chief of breast medical oncology at the City of Hope Cancer Center, and I'm also the editor-in-chief of the Educational Book. Rising healthcare costs are causing financial distress for patients and their families across the globe. Patients with cancer report financial toxicity as a major impediment to their quality of life, and its association with worse outcomes is well documented. Today, we'll be discussing how patients with breast cancer are uniquely at risk for financial toxicity. Joining me for this discussion is Dr. Kamaria Lee, a fourth-year radiation oncology resident and health equity researcher at MD Anderson Cancer Center and a co-author of the recently published article titled, "Financial Toxicity in Breast Cancer: Why Does It Matter, Who Is at Risk, and How Do We Intervene?" Our full disclosures are available in the transcript of this episode.  Dr. Lee, it's great to have you on this podcast. Dr. Kamaria Lee: Hey, Dr. Rugo. Thank you so much for having me. I'm excited to be here today. I also would like to recognize my co-authors, Dr. Alexandru Eniu, Dr. Christopher Booth, Molly MacDonald, and Dr. Fumiko Chino, who worked on this book chapter with me and did a fantastic presentation on the topic at ASCO this past year. Dr. Hope Rugo: Thanks very much. We'll now just jump into the questions. We know that rising medical costs contribute to a growing financial burden on patients, which has [GC1]  [JG2]  been documented to contribute to lower quality-of-life, compromised clinical care, and worse health outcomes. How are patients with breast cancer uniquely at risk for financial toxicity? How does the problem vary within the breast cancer population in terms of age, racial and ethnic groups, and those who have metastatic disease? Dr. Kamaria Lee: Breast cancer patients are uniquely at risk of financial toxicity for several reasons. Three key reasons are that breast cancer often requires multimodal treatment. So this means patients are receiving surgery, many receive systemic therapies, including hormonal therapies, as well as radiation. And so this requires care coordination and multiple visits that can increase costs. Secondly, another key reason that patients with breast cancer are uniquely at risk for financial toxicity is that there's often a long survivorship period that includes long-term care for toxicities and continued follow-ups, and patients might also be involved in activities regarding advocacy, but also physical therapy and mental health appointments during their prolonged survivorship, which can also add costs. And a third key reason that patients with breast cancer are uniquely at risk for financial toxicity is that the patient population is primarily women. And we know that women are more likely to have increased caregiver responsibilities while also potentially working and managing their treatments, and so this is another contributor. Within the breast cancer population, those who are younger and those who are from marginalized racial/ethnic groups and those with metastatic disease have been shown to be at an increased risk. Those who are younger may be more likely to need childcare during treatment if they have kids, or they're more likely to be employed and not yet retired, which can be disrupted while receiving treatment. And those who are racial/ethnic minorities may have increased financial toxicity due to reasons that exist even after controlling for socioeconomic factors. And some of these reasons have been shown to be increased risk of job or income loss or transportation barriers during treatment. And lastly, for those with metastatic breast cancer, there can be ongoing financial distress due to the long-term care that is needed for treatment, and this can include parking, transportation, and medications while managing their metastatic disease. Dr. Hope Rugo: I think it is really important to understand these issues as you just outlined. There has been a lot of focus on financial toxicity research in recent years, and that has led to novel approaches in screening for financial hardship. Can you tell us about the new screening tools and interventions and how you can easily apply that to clinical practice, keeping in mind that people aren't at MD Anderson with a bunch of support and information on this but are in clinical practice and seeing many, many patients a day with lots of different cancers? Dr. Kamaria Lee: You're exactly right that there is incredible nuance needed in understanding how to best screen for financial hardship in different types of practices. There are multiple financial toxicity tools. The most commonly used tool is the Comprehensive Score for Financial Toxicity, also known as the COST tool. In its full form, it's an 11-item survey. There's also a summary question as well. And these questions look at objective and subjective financial burden, and it uses a five-point Likert scale. For example, one question on the full form is, "I know that I have enough money in savings, retirement, or assets to cover the cost of my treatment," and then patients are able to respond "not at all" to "very much" with a threshold score for financial toxicity risk. Of course, as you noted, one critique of having an 11-item survey is that there's limited time in patient encounters with their providers. And so recently, Thom et al validated an abbreviated two-question version of the COST tool. This validation was done in an urban comprehensive cancer center, and it was found to have a high predictive value to the full measure. We note which two questions are specifically pulled from the full measure within the book chapter. And this is one way that it can be easier for clinicians who are in a busier setting to still screen for financial toxicity with fewer questions. I also do recommend that clinicians who know their clinic's workflow the best, work with their team of nurses, financial navigators, and others to best integrate the tool into their workflow. For some, this may mean sending the two-item survey as a portal message so that patients can answer it before consults. Other times, it could mean having it on the tablet that can be done in the clinic waiting room. And so there are different ways that screening can be done, even in a busy setting, and acknowledging that different practices have different amounts of resources and time. Dr. Hope Rugo: And where would people access that easily? I recognize that that information is in your chapter, or your article that's on PubMed that will be linked to this podcast, but it is nice to just know where people could easily access that online. Dr. Kamaria Lee: Yes, and so you should be able to Google ‘the COST measure’, and then there is a website that also has the forms as well. So it's also beyond the book chapter, Googling ‘the COST measure’, and then online they would be able to find access to the form. Dr. Hope Rugo: And how often would you do that screening? Dr. Kamaria Lee: So, I think it's definitely important that we are as proactive as possible. And so initially, I recommend that the screening happens at the time of diagnosis, and so if it's done through the portal, it can be sent before the initial consult, or again, however, is best in the workflow. So at the time of diagnosis and then at regular intervals, so throughout the treatment process, but then also into the follow-up period as well to best understand if there's still a financial burden even after the treatments have been completed. Dr. Hope Rugo: I wonder if in the metastatic setting, you could do it at the change of treatment, you know, a month after somebody's changed treatment, because people may not be as aware of the financial constraints when they first get prescribed a drug. It's more when you hear back from how much it's going to cost. And leading into that, I think it's, what do you do with this? So, you know, this cost conversation is really important. You're going to be talking to the patient about the cost considerations when you, for example, see that there are financial issues, you're prescribing treatments. How do we implement impactful structured cost conversations with our breast cancer patients, help identify financial issues, and intervene? How do we intervene? I mean, as physicians often we aren't really all that aware, or providers, of how to address the cost. Dr. Kamaria Lee: Yes, I agree fully that another key time when to screen for financial toxicity is at that transition between treatments to best understand where they're at based off of what they've received previously for care, and then to anticipate needs when changing regimens, such as like you said in the metastatic setting. As we're collecting this information, you're right, we screen, we get this information, and what do we do? I do agree that there is a lack of knowledge among us clinicians of how do we manage this information. What is insurance? How do we manage insurance and help patients with insurance concerns? How do we help them navigate out-of-pocket costs or even the indirect costs of transportation? Those are a lot of things that are not covered in-depth in traditional medical training. And so it can be overwhelming for a lot of clinicians, not only due to time limitations in clinic, but also just having those conversations within their visit. And so what I would say, a key thing to note, is that this is another area for multidisciplinary care. So just as we're

Drs. Hope Rugo, Sheri Brenner, and Mikolaj Slawkowski-Rode discuss the struggle that health care professionals experience when terminally ill patients are suffering and approaches to help clinicians understand and respond to suffering in a more patient-centered and therapeutic way. TRANSCRIPT Dr. Hope Rugo: Hello, and welcome to By the Book, a monthly podcast series from ASCO that features engaging conversations between editors and authors of the ASCO Educational Book.  I’m your host, Dr. Hope Rugo. I’m director of the Women’s Cancers Program and division chief of breast medical oncology at the City of Hope Cancer Center, and I’m also the editor-in-chief of the Educational Book. On today’s episode, we’ll be exploring the complexities of grief and oncology and the struggle we experience as healthcare professionals when terminally ill patients are suffering. Our guests will discuss approaches to help clinicians understand and respond to suffering in a more patient-centered and therapeutic way, as outlined in their recently published article titled, “Oncology and Suffering: Strategies on Coping With Grief for Healthcare Professionals.” I’m delighted today to welcome Dr. Keri Brenner, a clinical associate professor of medicine, palliative care attending, and psychiatrist at Stanford University, and Dr. Mikołaj Sławkowski-Rode, a senior research fellow in philosophy in the Humanities Research Institute at the University of Buckingham, where he also serves as director of graduate research in p hilosophy. He is also a research fellow in philosophy at Blackfriars Hall at the University of Oxford and associate professor at the University of Warsaw.  Our full disclosures are available in the transcript of this episode. Dr. Brenner and Dr. Sławkowski-Rode, thanks for being on the podcast today. Dr. Keri Brenner: Great to be here, Dr. Rugo. Thank you so much for that kind introduction. Dr. Mikołaj Sławkowski-Rode: Thank you very much, Dr. Rugo. It’s a pleasure and an honor. Dr. Hope Rugo: So I’m going to start with some questions for both of you. I’ll start with Dr. Brenner. You’ve spoken and written about the concept of suffering when there is no cure. For oncologists, what does it mean to attune to suffering, not just disease? And how might this impact the way they show up in difficult conversations with patients? Dr. Keri Brenner: Suffering is something that’s so omnipresent in the work of clinical oncology, and I like to begin by just thinking about what is suffering, because it’s a word that we use so commonly, and yet, it’s important to know what we’re talking about. I think about the definition of Eric Cassell, who was a beloved mentor of mine for decades, and he defined suffering as the state of severe distress that’s associated with events that threaten the intactness of a person. And my colleague here at Stanford, Tyler Tate, has been working on a definition of suffering that encompasses the experience of a gap between how things are versus how things ought to be. Both of these definitions really touch upon suffering in a person-centered way that’s relational about one’s identity, meaning, autonomy, and connectedness with others. So these definitions alone remind us that suffering calls for a person-centered response, not the patient as a pathology, but the panoramic view of who the patient is as a person and their lived reality of illness. And in this light, the therapeutic alliance becomes one of our most active ingredients in care. The therapeutic alliance is that collaborative, trusting bond as persons that we have between clinician and patient, and it’s actually one of the most powerful predictors of meaningful outcomes in our care, especially in oncologic care.  You know, I’ll never forget my first day of internship at Massachusetts General Hospital. A faculty lecturer shared this really sage insight with us that left this indelible mark. She shared, “As physicians and healers, your very self is the primary instrument of healing. Our being is the median of the medicine.” So, our very selves as embodied, relationally grounded people, that’s the median of the medicine and the first most enduring medicine that we offer. That has really borne fruit in the evidence that we see around the therapeutic alliance. And we see this in oncologic care, that in advanced cancer, a strong alliance with one’s oncologist truly improves a patient’s quality of life, treatment adherence, emotional well-being, and even surpasses structured interventions like psychotherapeutic interventions. Dr. Hope Rugo: That’s just incredibly helpful information and actually terminology as well, and I think the concept of suffering differs so much. Suffering comes in many shapes and forms, and I think you really have highlighted that. But many oncologists struggle with knowing what to do when patients are suffering but can’t be fixed, and I think a lot of times that has to do with oncologists when patients have pain or shortness of breath or issues like that. There are obviously many ways people suffer. But I think what’s really challenging is how clinicians understand suffering and what the best approaches to respond to suffering are in the best patient-centered and therapeutic way. Dr. Keri Brenner: I get that question a lot from my trainees in palliative care, not knowing what to do. And my first response is, this is about how to be, not about knowing what to do, but how to be. In our medical training, we’re trained often how to think and treat, but rarely how to be, how to accompany others. And I often have this image that I tell my trainees of, instead of this hierarchical approach of a fix-it mentality of all we’re going to do, when it comes to elements of unavoidable loss, mortality, unavoidable sufferings, I imagine something more like accompaniment, a patient walking through some dark caverns, and I am accompanying them, trying to walk beside them, shining a light as a guide throughout that darkness. So it’s a spirit of being and walking with. And it’s so tempting in medicine to either avoid the suffering altogether or potentially overidentify with it, where the suffering just becomes so all-consuming like it’s our own. And we’re taught to instead strike a balance of authentic accompaniment through it. I often teach this key concept in my palli-psych work with my team about formulation. Formulation is a working hypothesis. It’s taking a step back and asking, “Why? Why is this patient behaving in this manner? What might the patient’s core inner struggle be?” Because asking that “why” and understanding the nuanced dimensions of a patient’s core inner struggle will really help guide our therapeutic interactions and guide the way that we accompany them and where we choose to shine that light as we’re walking with them. And oftentimes people think, “Well Keri, that sounds so sappy or oversentimental,” and it’s not. You know, I’m just thinking about a case that I had a couple months ago, and it was a 28-year-old man with gastric cancer, metastatic disease, and that 28-year-old man, he was actually a college Division I athlete, and his dad was an acclaimed Division I coach. And our typical open-ended palliative care questions, that approach, infuriated them. They needed to know that I was showing up confident, competent, and that I was ready, on my A-game, with a real plan for them to follow through. And so my formulation about them was they needed somebody to show up with that confidence and competence, like the Division I athletes that they were, to really meet them and accompany them where they were on how they were going to walk through that experience of illness. Dr. Hope Rugo: These kinds of insights are so helpful to think about how we manage something that we face every day in oncology care. And I think that there are many ways to manage this.  Maybe I’ll ask Dr. Sławkowski-Rode one question just that I think sequences nicely with what you’re talking about.  A lot of our patients are trying to think about sort of the bigger picture and how that might help clinicians understand and support patients. So, the whole concept of spirituality, you know, how can we really use that as oncology clinicians to better understand and support patients with advanced illness, and how can that help patients themselves? And we’ll talk about that in two different ways, but we’ll just start with this broader question. Dr. Mikołaj Sławkowski-Rode: I think spirituality, and here, I usually refer to spirituality in terms of religious belief. Most people in the world are religious believers, and it is very intuitive and natural that religious beliefs would be a resource that people who help patients with a terminal diagnosis and healthcare professionals who work with those patients appeal to when they try to help them deal with the trauma and the stress of these situations.  Now, I think that the interesting thing there is that very often the benefit of appealing to a religious belief is misunderstood in terms of what it delivers. And there are many, many studies on how religious belief can be used to support therapy and to support patients in getting through the experience of suffering and defeating cancer or facing a terminal diagnosis. There’s a wealth of literature on this. But most of the literature focuses on this idea that by appealing to religious belief, we help patients and healthcare practitioners who are working with them get over the fact and that there’s a terminal diagnosis determining the course of someone’s life and get on with our lives and engaging with whatever other pursuits we might have, with our job if we’re healthcare practitioners, and with the other things that we might be passionate about in our lives. And the idea here is that this is what religion allows us to do because we sort of defer the need to worry about what’s going to happen to us until the afterlife or some perspective beyond the horizon of our life here. 

Dr. Nathan Pennell and Dr. Cheryl Czerlanis discuss challenges in lung cancer screening and potential solutions to increase screening rates, including the use of AI to enhance risk prediction and screening processes. Transcript Dr. Nate Pennell: Hello, and welcome to By the Book, a monthly podcast series for ASCO Education that features engaging discussions between editors and authors from the ASCO Educational Book. I'm Dr. Nate Pennell, the co-director of the Cleveland Clinic Lung Cancer Program and vice chair of clinical research for the Taussig Cancer Center. I'm also the editor-in-chief for the ASCO Educational Book.  Lung cancer is one of the leading causes of cancer-related mortality worldwide, and most cases are diagnosed at advanced stages where curative treatment options are limited. On the opposite end, early-stage lung cancers are very curable. If only we could find more patients at that early stage, an approach that has revolutionized survival for other cancer types such as colorectal and breast cancer.  On today's episode, I'm delighted to be joined by Dr. Cheryl Czerlanis, a professor of medicine and thoracic medical oncologist at the University of Wisconsin Carbone Cancer Center, to discuss her article titled, "Broadening the Net: Overcoming Challenges and Embracing Novel Technologies in Lung Cancer Screening." The article was recently published in the ASCO Educational Book and featured in an Education Session at the 2025 ASCO Annual Meeting. Our full disclosures are available in the transcript of this episode.  Cheryl, it's great to have you on the podcast today. Thanks for being here. Dr. Cheryl Czerlanis: Thanks, Nate. It’s great to be here with you. Dr. Nate Pennell: So, I'd like to just start by asking you a little bit about the importance of lung cancer screening and what evidence is there that lung cancer screening is beneficial. Dr. Cheryl Czerlanis: Thank you. Lung cancer screening is extremely important because we know that lung cancer survival is closely tied to stage at diagnosis. We have made significant progress in the treatment of lung cancer, especially over the past decade, with the introduction of immunotherapies and targeted therapies based on personalized evaluation of genomic alterations. But the reality is that outside of a lung screening program, most patients with lung cancer present with symptoms related to advanced cancer, where our ability to cure the disease is more limited.  While lung cancer screening has been studied for years, the National Lung Screening Trial, or the NLST, first reported in 2011 a significant reduction in lung cancer deaths through screening. Annual low-dose CT scans were performed in a high-risk population for lung cancer in comparison to chest X-ray. The study population was comprised of asymptomatic persons aged 55 to 74 with a 30-pack-year history of smoking who were either active smokers or had quit within 15 years. The low-dose CT screening was associated with a 20% relative risk reduction in lung cancer-related mortality. A similar magnitude of benefit was also reported in the NELSON trial, which was a large European randomized trial comparing low-dose CT with a control group receiving no screening. Dr. Nate Pennell: So, this led, of course, to approval from CMS (Centers for Medicare and Medicaid Services) for lung cancer screening in the Medicare population, probably about 10 years ago now, I think. And there are now two major trials showing an unequivocal reduction in lung cancer-related mortality and even evidence that it reduces overall mortality with lung cancer screening. But despite this, lung cancer screening rates are very low in the United States. So, first of all, what's going on? Why are we not seeing the kinds of screening rates that we see with mammography and colonoscopy? And what are the barriers to that here? Dr. Cheryl Czerlanis: That's a great question. Thank you, Nate. In the United States, recruitment for lung cancer screening programs has faced numerous challenges, including those related to socioeconomic, cultural, logistical, and even racial disparities. Our current lung cancer screening guidelines are somewhat imprecise and often fail to address differences that we know exist in sex, smoking history, socioeconomic status, and ethnicity. We also see underrepresentation in certain groups, including African Americans and other minorities, and special populations, including individuals with HIV. And even where lung cancer screening is readily available and we have evidence of its efficacy, uptake can be low due to both provider and patient factors. On the provider side, barriers include having insufficient time in a clinic visit for shared decision-making, fear of missed test results, lack of awareness about current guidelines, concerns about cost, potential harms, and evaluating both true and false-positive test results.  And then on the patient side, barriers include concerns about cost, fear of getting a cancer diagnosis, stigma associated with tobacco smoking, and misconceptions about the treatability of lung cancer. Dr. Nate Pennell: I think those last two are really what make lung cancer unique compared to, say, for example, breast cancer, where there really is a public acceptance of the value of mammography and that breast cancer is no one's fault and that it really is embraced as an active way you can take care of yourself by getting your breast cancer screening. Whereas in lung cancer, between the stigma of smoking and the concern that, you know, it's a death sentence, I think we really have some work to be made up, which we'll talk about in a minute about what we can do to help improve this.  Now, that's in the U.S. I think things are probably, I would imagine, even worse when we leave the U.S. and look outside, especially at low- and middle-income countries. Dr. Cheryl Czerlanis: Yes, globally, this issue is even more complex than it is in the United States. Widespread implementation of low-dose CT imaging for lung cancer screening is limited by manpower, infrastructure, and economic constraints. Many low- and middle-income countries even lack sufficient CT machines, trained personnel, and specialized facilities for accurate and timely screenings. Even in urban centers with advanced diagnostic facilities, the high screening and follow-up care costs can limit access. Rural populations face additional barriers, such as geographic inaccessibility of urban centers, transportation costs, language barriers, and mistrust of healthcare systems. In addition, healthcare systems in these regions often prioritize infectious diseases and maternal health, leaving limited room for investments in noncommunicable disease prevention like lung cancer screening. Policymakers often struggle to justify allocating resources to lung cancer screening when immediate healthcare needs remain unmet. Urban-rural disparities exacerbate these challenges, with rural regions frequently lacking the infrastructure and resources to sustain screening programs. Dr. Nate Pennell: Well, it's certainly an intimidating problem to try to reduce these disparities, especially between the U.S. and low- and middle-income countries. So, what are some of the potential solutions, both here in the U.S. and internationally, that we can do to try to increase the rates of lung cancer screening? Dr. Cheryl Czerlanis: The good news is that we can take steps to address these challenges, but a multifaceted approach is needed. Public awareness campaigns focused on the benefits of early detection and dispelling myths about lung cancer screening are essential to improving participation rates. Using risk-prediction models to identify high-risk individuals can increase the efficiency of lung cancer screening programs. Automated follow-up reminders and screening navigators can also ensure timely referrals and reduce delays in diagnosis and treatment. Reducing or subsidizing the cost of low-dose CT scans, especially in low- or middle-income countries, can improve accessibility. Deploying mobile CT scanners can expand access to rural and underserved areas.  On a global scale, integrating lung cancer screening with existing healthcare programs, such as TB or noncommunicable disease initiatives, can enhance resource utilization and program scalability. Implementing lung cancer screening in resource-limited settings requires strategic investment, capacity building, and policy interventions that prioritize equity. Addressing financial constraints, infrastructure gaps, and sociocultural barriers can help overcome existing challenges. By focusing on cost-effective strategies, public awareness, and risk-based eligibility criteria, global efforts can promote equitable access to lung cancer screening and improve outcomes.  Lastly, as part of the medical community, we play an important role in a patient's decision to pursue lung cancer screening. Being up to date with current lung cancer screening recommendations, identifying eligible patients, and encouraging a patient to undergo screening often is the difference-maker. Electronic medical record (EMR) systems and reminders are helpful in this regard, but relationship building and a recommendation from a trusted provider are really essential here. Dr. Nate Pennell: I think that makes a lot of sense. I mean, there are technology improvements. For example, our lung cancer screening program at The Cleveland Clinic, a few years back, we finally started an automated best practice alert in our EMR for patients who met the age and smoking requirements, and it led to a six-fold increase in people referred for screening. But at the same time, there's a difference between just getting this alert and putting in an order for lung cancer screening and actually getting those patients to go and actually do the screening and then follow up on it. And that, of course, requires having that relationship and discussion with the patient so that they tru

Host Dr. Nate Pennell and his guest, Dr. Chloe Atreya, discuss the ASCO Educational Book article, “Integrative Oncology: Incorporating Evidence-Based Approaches to Patients With GI Cancers,” highlighting the use of mind-body approaches, exercise, nutrition, acupuncture/acupressure, and natural products. Transcript Dr. Nate Pennell: Welcome to ASCO Education: By the Book, our new monthly podcast series that will feature engaging discussions between editors and authors from the ASCO Educational Book. We'll be bringing you compelling insights on key topics featured in Education Sessions at ASCO meetings and some deep dives on the approaches shaping modern oncology.  I'm Dr. Nate Pennell, director of the Cleveland Clinic Lung Cancer Medical Oncology Program as well as vice chair of clinical research for the Taussig Cancer Institute. Today, I'm delighted to welcome Dr. Chloe Atreya, a professor of Medicine in the GI Oncology Group at the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, and the UCSF Osher Center for Integrative Health, to discuss her article titled, “Integrative Oncology Incorporating Evidence-Based Approaches to Patients With GI Cancers”, which was recently published in the ASCO Educational Book. Our full disclosures are available in the transcript of this episode.  Dr. Atreya, it's great to have you on the podcast today. Thanks for joining me. Dr. Chloe Atreya: Thanks Dr. Pennell. It's a pleasure to be here. Dr. Nate Pennell: Dr. Atreya, you co-direct the UCSF Integrative Oncology Program with a goal to really help patients with cancer live as well as possible. And before we dive into the review article and guidelines, I'd love to just know a little bit about what inspired you to go into this field? Dr. Chloe Atreya: Yeah, thank you for asking. I've had a long-standing interest in different approaches to medicine from global traditions and I have a degree in pharmacology, and I continue to work on new drug therapies for patients with colorectal cancer. And one thing that I found is that developing new drugs is a long-term process and often we're not able to get the drugs to the patients in front of us. And so early on as a new faculty member at UCSF, I was trying to figure out what I could do for the patient in front of me if those new drug therapies may not be available in their lifetime. And one thing I recognized was that in some conversations the patient and their family members, even if the patient had metastatic disease, they were able to stay very present and to live well without being sidelined by what might happen in the future. And then in other encounters, people were so afraid of what might be happening in the future, or they may have regrets maybe about not getting that colonoscopy and that was eroding their ability to live well in the present.  So, I started asking the patients and family members who were able to stay present, “What's your secret? How do you do this?” And people would tell me, “It's my meditation practice,” or “It's my yoga practice.” And so, I became interested in this. And an entry point for me, and an entry point to the Osher Center at UCSF was that I took the Mindfulness-Based Stress Reduction Program to try to understand experientially the evidence for this and became very interested in it. I never thought I would be facilitating meditation for patients, but it became a growing interest. And as people are living longer with cancer and are being diagnosed at younger ages, often with young families, how one lives with cancer is becoming increasingly important.   Dr. Nate Pennell: I've always been very aware that it seemed like the patients that I treated who had the best quality of life during their life with cancer, however that ended up going, were those who were able to sort of compartmentalize it, where, when it was time to focus on discussing treatment or their scans, they were, you know, of course, had anxiety and other things that went along with that. But when they weren't in that, they were able to go back to their lives and kind of not think about cancer all the time. Whereas other people sort of adopt that as their identity almost is that they are living with cancer and that kind of consumes all of their time in between visits and really impacts how they're able to enjoy the rest of their lives. And so, I was really interested when I was reading your paper about how mindfulness seemed to be sort of like a formal way to help patients achieve that split. I'm really happy that we're able to talk about that. Dr. Chloe Atreya: Yeah, I think that's absolutely right. So, each of our patients is more than their cancer diagnosis. And the other thing I would say is that sometimes patients can use the cancer diagnosis to get to, “What is it that I really care about in life?” And that can actually heighten an experience of appreciation for the small things in life, appreciation for the people that they love, and that can have an impact beyond their lifetime. Dr. Nate Pennell: Just in general, I feel like integrative medicine has come a long way, especially over the last decade or so. So, there's now mature data supporting the incorporation of elements of integrative oncology into comprehensive cancer care. We've got collaborations with ASCO. They've published clinical practice guidelines around diet, around exercise, and around the use of cannabinoids. ASCO has worked with the Society for Integrative Oncology to address management of pain, anxiety, depression, fatigue – lots of different evidence bases now to try to help guide people, because this is certainly something our patients are incredibly interested in learning about. Can you get our listeners up to speed a little bit on the updated guidelines and resources supporting integrative oncology? Dr. Chloe Atreya: Sure. I can give a summary of some of the key findings. And these are rigorous guidelines that came together by consensus from expert panels. I had the honor of serving on the anxiety and depression panel. So, these panels will rate the quality of the evidence available to come up with a strength of recommendation. I think that people are at least superficially aware of the importance of diet and physical activity and that cannabis and cannabinoids have evidence of benefit for nausea and vomiting. They may not be aware of some of the evidence supporting these other modalities. So, for anxiety and depression, mindfulness-based interventions, which include meditation and meditative movement, have the strongest level of evidence. And the clinical practice guidelines indicate that they should be offered to any adult patient during or after treatment who is experiencing symptoms of anxiety or depression. Other modalities that can help with anxiety and depression include yoga and Tai Chi or Qigong. And with the fatigue guidelines, mindfulness-based interventions are also strongly recommended, along with exercise and cognitive behavioral therapy, Tai Chi and Qigong during treatment, yoga after treatment.  And some of these recommendations also will depend on where the evidence is. So, yoga is an example of an intervention that I think can be helpful during treatment, but most of our evidence is on patients who are post-treatment. So, most of our guidelines separate out during treatment and the post-treatment phase because the quality of evidence may be different for these different phases of treatment.  With the pain guidelines, the strongest recommendation is for acupuncture, specifically for people with breast cancer who may be experiencing joint pain related to aromatase inhibitors. However, acupuncture and other therapies, including massage, can be helpful with pain as well. So those are a few of the highlights. Dr. Nate Pennell: Yeah, I was surprised at the really good level of evidence for the mindfulness-based practices because I don't think that's the first thing that jumps to mind when I think about integrative oncology. I tend to think more about physical interventions like acupuncture or supplements or whatnot. So, I think this is really fantastic that we're highlighting this.  And a lot of these interventions like the Qigong, Tai Chi, yoga, is it the physical practice of those that benefits them or is it that it gives them something to focus on, to be mindful of? Is that the most important intervention? It doesn't really matter what you're doing as long as you have something that kind of takes you out of your experience and allows you to focus on the moment. Dr. Chloe Atreya: I do think it is a mind, body and spirit integration, so that all aspects are important. We also say that the best practice is the one that you actually practice. So, part of the reason that it's important to have these different modalities is that not everybody is going to take up meditation. And there may be people for whom stationary meditation, sitting and meditating, works well, and other people for whom meditative movement practices may be what they gravitate to. And so, I think that it's important to have a variety of options. And one thing that's distinct from some of our pharmacologic therapies is that the safety of these is, you know, quite good. So, it becomes less important to say, “Overall, is Tai Chi better or is yoga better?” for instance. It really depends on what it is that someone is going to take up. Dr. Nate Pennell: And of course, something that's been really nice evidence-based for a long time, even back when I was in my training in the 2000s with Jennifer Temel at Massachusetts General Hospital, was the impact of physical activity and exercise on patients with cancer. It seems like that is pretty much a universally good recommendation for patients. Dr. Chloe Atreya: Yes, that's absolutely right. Physical activity has been associated with improved survival after a cancer diagnosis. And that's both cancer specific survival and

On the inaugural episode of ASCO Education: By the Book, Dr. Nathan Pennell and Dr. Don Dizon share reflections on the evolution of the ASCO Educational Book, its global reach, and the role of its new companion podcast to further shine a spotlight on the issues shaping the future of modern oncology. TRANSCRIPT Dr. Nathan Pennell: Hello, I'm Dr. Nate Pennell, welcoming you to the first episode of our new podcast, ASCO Education: By the Book. The podcast will feature engaging discussions between editors and authors from the ASCO Educational Book. Each month, you'll hear nuanced views on key topics in oncology featured in Education Sessions at ASCO meetings, as well as some deep dives on the advances shaping modern oncology. Although I am honored to serve as the editor-in-chief (EIC) of the ASCO Educational Book, in my day job, I am the co-director of the Cleveland Clinic Lung Cancer Program and vice chair for clinical research for the Taussig Cancer Center here in Cleveland. I'm delighted to kick off our new podcast with a discussion featuring the Ed Book's previous editor-in-chief. Dr. Don Dizon is a professor of medicine and surgery at Brown University and works as a medical oncologist specializing in breast and pelvic malignancies at Lifespan Cancer Institute in Rhode Island. Dr. Dizon also serves as the vice chair for membership and accrual at the SWOG Cancer Research Network. Don, it's great to have you here for our first episode of ASCO Education: By the Book. Dr. Don Dizon: Really nice to be here and to see you again, my friend. Dr. Nathan Pennell: This was the first thing I thought of when we were kicking off a podcast that I thought we would set the stage for our hopefully many, many listeners to learn a little bit about what the Ed Book used to be like, how it has evolved over the last 14 years or so since we both started here and where it's going. You started as editor-in-chief in 2012, is that right? Dr. Don Dizon: Oh, boy. I believe that is correct, yes. I did two 5-year stints as EIC of the Educational Book, so that sounds about right. Although you're aging me very clearly on this podcast. Dr. Nathan Pennell: I had to go back in my emails to see if I could figure out when we started on this because we've been working on it for some time. Start out a little bit by telling me what do you remember about the Ed Book from back in the day when you were applying to be editor-in-chief and thinking about the Ed Book. What was it like at that time? Dr. Don Dizon: You know, it's so interesting to think about it.  Ten years ago, we were both in a very different place in our careers, and I remember when the Ed Book position came up, I had been writing a column for ASCO. I had done some editorial activities with other journals for sure, but what always struck me was it was very unclear how one was chosen to be a part of the education program at ASCO. And then it was very unclear how those faculty were then selected to write a paper for the Educational Book. And it was back in the day when the Educational Book was completely printed. So, there was this book that was cherished among American fellows in oncology. And it was one that, when I was newly attending, and certainly two or three years before the editor's position came up, it was one that I referenced all the time. So, it was a known commodity for many of us. And there was a certain sense of selectivity about who was invited to write in it. And it wasn't terribly transparent either. So, when the opportunity to apply for editor-in-chief of the Educational Book came up, I had already been doing so much work for ASCO. I had been on the planning committees and served in many roles across the organization, and editing was something I found I enjoyed in other work. So, I decided to put my name in the ring with the intention of sort of bringing the book forward, getting it indexed, for example, so that there was this credit that was more than just societal credit at ASCO. This ended up being something that was referenced and acknowledged as an important paper through PubMed indexing. And then also to provide it as a space where we could be more transparent about who was being invited and broadening the tent as to who could participate as an author in the Ed Book. Dr. Nathan Pennell: It's going to be surprising to many of our younger listeners to learn that the Educational Book used to be just this giant, almost like a brick. I mean, it was this huge tome of articles from the Education Sessions that you got when you got your meeting abstracts book at the annual meeting. And you can always see people on the plane on the way out of Chicago with their giant books. Dr. Don Dizon: Yes. Dr. Nathan Pennell: That added lots of additional weight to the plane, I'm sure, on the way out. Dr. Don Dizon: And it was not uncommon for us to be sitting at an airport, and people would be reading those books with highlighters. Dr. Nathan Pennell: I fondly remember being a fellow and coming up and the Ed Book was always really important to me, so I was excited. We'll also let the listeners in on that. I also applied to be the original editor-in-chief of the Ed Book back in 2012, although I was very junior and did not have any real editorial experience. I think I may have been section editor for The Oncologist at that point. And I had spoken to Dr. Ramaswamy Govindan at WashU who had been the previous editor-in-chief about applying and he was like, “Oh yeah. You should absolutely try that out.” And then when Dr. Dizon was chosen, I was like, “Oh, well. I guess I didn't get it.” And then out of the blue I got a call asking me to join as the associate editor, which I was really always very thankful for that opportunity. Dr. Don Dizon: Well, it was a highly fruitful collaboration, I think, between you and I when we first started. I do remember taking on the reins and sort of saying, “You know, this is our vision of what we want to do.” But then just working with the authors, which we did, about how to construct their papers and what we were looking for, all of that is something I look back really fondly on. Dr. Nathan Pennell: I think it was interesting too because neither one of us had really a lot of transparency into how things worked when we started. We kind of made it up a little bit as we went along. We wanted to get all of the faculty, or at least as many of them as possible contributing to these. And we would go to the ASCO Education Committee meeting and kind of talk about the Ed Book, and we were thinking about, you know, how could we get people to submit. So, at the time it wasn't PubMed indexed. Most people, I think, submitted individual manuscripts just from their talk, which could be anywhere from full length review articles to very brief manuscripts. Dr. Don Dizon: Sometimes it was their slides with like a couple of comments on it. Dr. Nathan Pennell: And some of them were almost like a summary of the talk. Yeah, exactly. And so sort of making that a little more uniform. There was originally an honorarium attached, which went away, but I think PubMed indexing was probably the biggest incentive for people to join. I remember that was one of the first things you really wanted to get. Dr. Don Dizon Yeah. And, you know, it was fortuitous. I'd like to take all the credit for it, but ASCO was very forward thinking with Dr. Ramaswamy and the conversations about going to PubMed with this had preceded my coming in. We knew what we needed to do to get this acknowledged, which was really strengthening the peer review so that these papers could meet the bar to get on PubMed. But you know, within the first, what, two or three years, Nate, of us doing this, we were able to get this accepted. And now it is. If you look at what PubMed did for us, it not only increased the potential of who was going to access it, but for, I think the oncology community, it allowed people access to papers by key opinion leaders that was not blocked by a paywall. And I thought that was just super important at the time. Social media was something, but it wasn't what it is now. But anybody could access these manuscripts and it's still the case today. Dr. Nathan Pennell: I think it's hard to overstate how important that was. People don't realize this, but the Ed Book is really widely accessed, especially outside the US as well. And a lot of people who can't attend the meeting to get the print, well, the once print, book could actually get access to essentially the education session from the annual meeting without having to fly all the way to the US to attend. Now, you know, we have much better virtual meeting offerings now and whatnot. But at the time it was pretty revolutionary to be able to do that. Dr. Don Dizon: Yeah, and you know, it's so interesting when I think back to, you know, this sort of evolution to a fully online publication of the Ed Book. It was really some requests from international participants of the annual meeting who really wanted to continue to see this in print. At that time, it was important to recognize that access to information was not uniform across the world. And people really wanted that print edition, maybe not for themselves, but so that access in more rural areas or where access in the broadband networks were not established that they still could access the book. I think things have changed now. We were able, I think, in your tenure, to see it fully go online. But even I just remember that being a concern as we went forward. Dr. Nathan Pennell: Yeah, we continued with the print book that was available if people asked for it, but apparently few enough people asked for it that it moved fully online. One of the major advantages of being fully online now is of course, it does allow us to publish kind of in real time as the manuscripts come out in the months leading up to the meeting, which has been, I think, a huge boon because it can build momentum for the Ed

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

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

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

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

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

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

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

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

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

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

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

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

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

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