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Blood & Cancer

Author: MDedge Hematology & Oncology

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Interview-style hematology/oncology podcast from MDedge Hematology-Oncology. The show is hosted by Dr. David Henry with Pearls from Dr. Ilana Yurkiewicz for clinical hematology and oncology health care professionals. The information in this podcast is provided for informational and educational purposes only.
53 Episodes
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Matt Kalaycio, MD, of the Cleveland Clinic joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to preview the potentially practice changing research that will be reported at the 2019 annual meeting of the American Society of Hematology. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, addresses the isolation that comes from dealing with a serious chronic illness, especially around the holidays. *  *  *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *  FDA approves atezolizumab combo as first line for advanced NSCLC Atezolizumab is a monoclonal antibody and is already approved for adults with metastatic NSCLC with disease progression. By Laura Nicolaides The Food and Drug administration as approved atezolizumab in combination with paclitaxel and carboplatin chemotherapy for first-line treatment of adults with metastatic, nonsquamous non-small cell lung cancer with no EGFR or ALK genomic tumor aberrations.  *  *  *  ASH abstracts discussed in the podcast: Abstract 1: Post-transplantation cyclophosphamide after allogeneic hematopoietic stem cell transplantation: Results of the prospective randomized HOVON-96 trial in recipients of matched related and unrelated donors. Abstract 261: Superior survival with post-remission pediatric-inspired chemotherapy compared to myeloablative allogeneic hematopoietic cell transplantation in adolescents and young adults with Ph-negative acute lymphoblastic leukemia in first complete remission: Comparison of CALGB 10403 to patients reported to the CIBMTR. Abstract 322: Nonmyeloablative allogeneic transplantation confers an overall survival benefit with similar nonrelapse mortality when compared with autologous stem transplantation for patients with relapsed follicular lymphoma. Abstract 6: Mosunetuzumab induces complete remissions in poor prognosis non-Hodgkin lymphoma patients, including those who are resistant to or relapsing after chimeric antigen receptor T-cell therapies, and is active in treatment through multiple lines. Abstract LBA-5: Validation of BCL11A as therapeutic target in sickle cell disease: Results from the adult cohort of a pilot/feasibility gene therapy trial inducing sustained expression of fetal hemoglobin using posttranscriptional gene silencing. Abstract LBA-6: Carfilzomib, dexamethasone, and daratumumab versus carfilzomib and dexamethasone for the treatment of patients with relapsed or refractory multiple myeloma: Primary analysis results from the randomized, open-label, phase 3 study Candor. Abstract 1588: A randomized trial of EPOCH-based chemotherapy with vorinostat for highly aggressive HIV-associated lymphomas: Updated results evaluating the impact of diagnosis-to-treatment interval and pre-protocol systemic therapy on outcomes. Abstract 940: Elucidating the role of IL6 in stress erythropoiesis and in the development of anemia under inflammatory conditions. Abstract 57: Patient harm from repetitive blood draws and blood waste in the ICU: A retrospective cohort study. Abstract 59: Impact of iron supplementation on patient outcomes in women undergoing gynecologic procedures: Systematic review and meta-analysis of randomized trials. Abstract 126: Polatuzumab vedotin plus obinutuzumab and lenalidomide in patients with relapsed/refractory follicular lymphoma: Primary analysis of the full efficacy population in a phase Ib/II trial. Abstract 168: Risk of hemorrhage in patient with polycythemia vera exposed to aspirin in combination with anticoagulants: Results of a prospective, multicenter, observational cohort study (REVEAL). Abstract 326: Safety and effectiveness of apixaban, LMWH, and warfarin among venous thromboembolism patients with active cancer: A retrospective analysis using four U.S. claims databases. Abstract 327: Safety and effectiveness of apixaban, LMWH and warfarin among venous thromboembolism patients with active cancer: A subgroup analysis of VTE risk scale. Abstract 566: Phase II study of oral rigosertib combined with azacytidine as first line therapy in patients with higher-risk myelodysplastic syndromes.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
In this special edition podcast, Blood & Cancer revisits an interview with Gary H. Lyman, MD, of Fred Hutchinson Cancer Research Center, Seattle, on defining and understanding biosimilars. Dr. Lyman joins host David H. Henry, MD, to explore the interchangeability of these drugs and how biosimilars are being integrated into clinical practice guidelines. *  *  *   Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *   This Week in Oncology ASH preview: Key themes include tackling CAR T obstacles, sickle cell advances, VTE By Sharon Worcester Chimeric antigen receptor (CAR) T-cell therapies have garnered a great deal of attention given their “incredible efficacy” in treating B-cell malignancies, and new findings are taking aim at the drawbacks of therapy, such as the time, expense, and toxicity involved. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
Jame Abraham, MD, of the Cleveland Clinic joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia to review two cases of breast cancer, focusing on when to use the 21-gene Oncotype DX breast recurrence score and how to apply the results.   Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, explores what happens when the patient minimizes their symptoms in order to keep getting treatment. *  *  *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *  This Week in Oncology Not all lung cancer patients receive treatment By Richard Franki In the United States, just over 15% of patients with lung cancer receive no treatment, according to the American Lung Association. *  *  *  Breast cancer cases Case 1: A 46-year-old, premenopausal woman who has had a right breast lumpectomy with a 7-mm tumor that is invasive ductal, ER/PR positive, and HER2 negative. Since her tumor is small and low grade, would you do Oncotype DX recurrence score testing? Dr. Abraham recommends: Explain to the patient that her benefit from chemotherapy will be limited, but that she meets the tumor size requirement for the Oncotype DX assay and offer her the test. Case 2: A 57-year-old women who is postmenopausal with a grade 1 tumor that is 10mm, ER/PR positive, HER2 negative, with 4 of 17 positive lymph nodes. Is there an advantage to adding the Oncotype DX testing for this patient? Dr. Abraham recommends: Offer the patient chemotherapy; recommend against Oncotype DX testing. Show notes by Mary Ellen Schneider   References Sparano JA et al. Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med. 2018 Jul 12;379(2):111-21. Sparano JA et al. Clinical and genomic risk to guide the use of adjuvant therapy for breast cancer. N Engl J Med. 2019 Jun 20;380(25):2395-2405. *  *  *  For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
Jack West, MD, joins the podcast to discuss the immunotherapy in the treatment of lung cancer. Dr. West is an associate clinical professor in medical oncology at City of Hope Comprehensive Cancer Center in Duarte, Calif., and a thought leader in thoracic oncology. Dr. West and Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, discuss assays, liquid biopsy, and review a recent case in part two of their interview. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, reminds us that even when just “covering” a patient for another physician, you could be in for some difficult discussions. *  *  *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *  This Week in Oncology Atezolizumab bests chemo in NSCLC patients with high PD-L1 expression by Jennifer Smith Atezolizumab monotherapy can improve overall survival in treatment-naive patients with stage IV non-small cell lung cancer and high PD-L1 expression according to the results of a phase 3 trial presented at the 2019 annual meeting of the Society for Immunotherapy of Cancer. Assays Important to rapidly test for PDL1, EGFR and ALK status and have all results before committing to first-line therapy. PDL1 testing results often take 24 hours, while EGFR and ALK results can take several weeks; committing to immunotherapy without knowing the status of molecular drivers is not ideal. Liquid biopsy Measures DNA from tumor cells circulating in the blood. Testing takes about a week. A positive result can be trusted. A negative result cannot be trusted, given low sensitivity, especially in patients with low tumor burden. Adverse effects of immunotherapy Striking variability in toxicity profiles among patients. Although overall better tolerated than chemotherapy, the “unknown” aspect of immunotherapy toxicities may be anxiety provoking for patients. Fatigue, rash, and thyroid abnormalities are most commonly seen. However, there is a broad array of toxicities that oncologists may not be familiar with, necessitating a multidisciplinary approach. Case discussion An otherwise healthy, middle-aged woman presents with two lung nodules: a 1.4 cm lesion in the left upper lobe, and a 3.1 cm lesion in the left lower lobe. Both are biopsy proven to be non–small cell adenocarcinoma. Both lesions are excised with clear margins. There is no lymph node, vascular, or pleural invasion. In this case, it makes sense to view these as two independent cancers. Unclear if the chance of recurrence is increased based on the presence of two, less than 4 cm lesions with negative prognostic features and adequate excision with clear margins. The anticipated benefit of adjuvant chemotherapy must be weighed against toxicities, and the individual patient’s ability to tolerate chemotherapy must be considered. Resources Dr. West’s cancer education website for patients and caregivers: cancergrace.org Show notes by Sugandha Landy, MD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. *  *  *  For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
  H. Jack West, MD, joins the podcast to discuss the latest trials of immunotherapies in the treatment of lung cancer. Dr. West is an associate clinical professor in medical oncology at City of Hope Comprehensive Cancer Center in Duarte, Calif., and a thought leader in thoracic oncology. Dr. West and Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, review Keynote-042, Keynote-189, and IMpower150, and discuss how the findings influence practice. You can find Dr. West on Twitter at @JackWestMD. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, discusses how to be nonjudgmental when talking to patients about how they got cancer. * * * Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * This Week in Oncology: FDA Approves Ziextenzo for neutropenia-related infection reduction The FDA has approved the biosimilar Ziextenzo to reduce the incidence of infection in patients with nonmyeloid cancer who are receiving suppressive anticancer drugs that are associated with febrile neutropenia. Treatment for metastatic nonsquamous non–small cell lung cancer (NSCLC) without EGFR mutation or ALK translocation: Keynote-042 Design: Pembrolizumab alone vs. chemotherapy alone (carboplatin plus paclitaxel or carboplatin plus pemetrexed) 902 patients 1:1 randomization All patients with at least 1% PDL1 positivity Stratified into three groups: greater than 1%, greater than 20%, and greater than 50% PDL1 score No crossover permitted between groups Results: Overall survival is 16.7 months with pembrolizumab vs. 12.1 months with chemotherapy. PDL1 score 1% or greater: 16.7 months for pembrolizumab vs. 12.1 months for chemotherapy alone. PDL1 score 20% or greater: 17.7 months for pembrolizumab vs. 13.0 months for chemotherapy alone. PDL1 score 50% or greater: 20.0 months for pembrolizumab vs. 12.2 months for chemotherapy alone. There was no statistically significant difference in progression-free survival. Conclusion: Pembrolizumab monotherapy can be extended as first-line therapy to patients with locally advanced or metastatic non–small cell lung cancer and a high PDL1 score. Pembrolizumab monotherapy alone may not be the best choice for patients with a low PLD1 score.   Keynote-189 Design: Pembrolizumab plus chemotherapy vs. placebo plus chemotherapy (pemetrexed plus platinum agent) 616 patients 2:1 randomization All patients with at least 1% PDL1 positivity Crossover to pembrolizumab monotherapy was permitted among the patients in the placebo-combination group who had verified disease progression Results: Overall survival to 12 months: 69.2% with pembrolizumab plus chemotherapy vs. 49.4% with chemotherapy alone. Progression-free survival: 8.8 months with pembrolizumab plus chemotherapy vs. 4.9 months with chemotherapy alone. Conclusion: Pembrolizumab should be added to standard chemotherapy of pemetrexed and a platinum-based drug for significantly longer overall survival and progression-free survival than chemotherapy alone, regardless of level of PDL1 positivity.   IMpower150 Design: Atezolizumab plus bevacizumab plus carboplatin plus paclitaxel (ABCP) vs. bevacizumab plus carboplatin plus paclitaxel (BCP) vs. atezolizumab plus carboplatin plus paclitaxel (ACP) 1,202 patients 1:1:1 randomization Patients with any PD-L1 immunohistochemistry status were eligible Stratified by level of Teff gene-signature expression Results: Overall survival was longer in the ABCP group than in the BCP group (19.2 months vs. 14.7 months). Progression-free survival was longer in the ABCP group than in the BCP group (8.3 months vs. 6.8 months). In the Teff-high population, progression-free survival was significantly longer in the ABCP group than in the BCP group (11.3 months vs. 6.8 months). Conclusion: Addition of atezolizumab to bevacizumab plus chemotherapy significantly improved progression-free survival and overall survival among patients with metastatic nonsquamous NSCLC, regardless of PD-L1 expression. Unclear if ABCP regimen is superior to pembrolizumab monotherapy (in greater than 50% PDL1 group) or pembrolizumab plus pemetrexed plus platinum agent (in all PDL1 groups) as a four-drug regimen may be less attractive than these options. Teff status has not yet been proven to be useful for clinical decision making.   References Mok TSK et al. Pembrolizumab versus chemotherapy for previously untreated, PD-L1-expressing, locally advanced or metastatic non–small cell lung cancer (KEYNOTE-042): A randomised, open-label, controlled, phase 3 trial. Lancet. 2019;393:1819-30.   Gandhi L et al. Pembrolizumab plus chemotherapy in metastatic non–small cell lung cancer. N Engl J Med. 2018;378:2078-92. Socinski MA et al. Atezolizumab for first-line treatment of metastatic nonsquamous NSCLC. N Engl J Med. 2018;378:2288-301.   Show notes by Sugandha Landy, MD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
David L. Streiner, PhD, of McMaster University, Hamilton, Ont., and the University of Toronto, joins Blood & Cancer host David Henry, MD, of Pennsylvania Hospital, Philadelphia, to explain what a post hoc analysis is and why it should be interpreted with caution. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, explores what to tell patients when it comes to prognostic scoring system results. * * *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * *  This week in Oncology: In rectal cancer, fragmented care linked to lower survival by Jim Kling, reporting from Clinical Congress 2019. Post hoc analyses What is a post hoc analysis? Analyzing data after a study has already had conclusions made and looking for patterns that were not prespecified. Dr. Streiner’s advice for researchers: Pick a small number of primary outcomes and develop a narrow hypothesis. Then use post hoc analysis as a means of assessing future questions that can be investigated in a subsequent study. Dr. Streiner’s advice for clinicians: Treat a post hoc analysis as a hypothesis that requires further study. It should be viewed with some degree of suspicion because it may have been significant only by chance. Show notes by Ronak Mistry, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   References Marcus R et al. Obinutuzumab for the first-line treatment of follicular lymphoma. N Engl J Med. 2017;377:1331-44. Crawford ED et al. Comorbidity and mortality results from a randomized prostate cancer screening trial. J Clin Oncol. 2011;29:355-61. Streiner DL et al. Size, follow-up, data analysis – good; post hoc analysis, interpretation – not so good. Commun Oncol. 2011;8:379-80.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
Strategies and guidelines for delivering bad news to patients from David Henry, MD, and Ilana Yurkiewicz, MD.  Timestamps: This week in Oncology (01:30) Conversation (04:22) This week, the host of Blood & Cancer and the writer, producer, and talent behind the Clinical Correlation segment sit down together for the first time ever.  Dr. Henry and Dr. Yurkiewicz share strategies and anecdotes about their experiences learning how to give patients terrible news and --perhaps more importantly -- how not to.  Links: SPIKES mnemonic Dr. Henry: Academic Biography Dr. Yurkiewicz Academic Biography Hard Questions column This week in Oncology.  Immunotherapy enables nephrectomy with good outcomes in advanced RCCby Susan London Some patients with advanced renal cell carcinoma treated with immune checkpoint inhibitors can safely undergo nephrectomy and experience favorable surgical outcomes and pathologic responses according to a cohort study from Urologic Oncology.  SOURCE: Singla N et al. Urol Oncol. 2019 Sep 12. doi: 10.1016/j.urolonc.2019.08.012 For more MDedge podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter @mdedgehemonc David Henry on Twitter @davidhenrymd Ilana Yurkiewicz on Twitter @ilanayurkiewicz  
Justine V. Cohen, DO, of the University of Pennsylvania, Philadelphia, joins Blood & Cancer host David H. Henry, MD, also of the University of Pennsylvania, to discuss a recent melanoma case in the adjuvant setting and when to consider targeted therapies or immune checkpoint inhibitors for these patients.  Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about what happens when a patient’s anxiety threatens to get in the way of the clinician’s decision making. Time stamps: Meet the guest (00:51) This Week in Oncology (03:02) Interview with Dr. Justine Cohen (05:48) Clinical Correlation (26:25) This week in Oncology FDA approves rivaroxaban for VTE prevention in hospitalized, acutely ill patients by Lucas Franki FDA approval for the new indication is based on results from the phase 3 MAGELLAN and MARINER trials, which included more than 20,000 hospitalized, acutely ill patients. Therapies for melanoma Classes of therapies for adjuvant melanoma include immune checkpoint inhibitors and targeted therapies. Historically, high-dose interferon was the only available therapy for melanoma. This was associated with a lot of toxicities, without great benefits in terms of overall survival. About 50% of melanomas are BRAF mutated and amendable to adjuvant treatment with the combination of BRAF/MEK inhibitors. Immunotherapy can be used in BRAF mutated patients or BRAF wild type (no mutation). Ipilimumab (anti-CTLA4) demonstrated recurrence-free survival benefit and an overall survival benefit. Toxicity = grade 3 or grade 4 immune-related side effects. Nivolumab and pembrolizumab (anti-PD1) have taken the place of ipilimumab. They are associated with lower rates of toxicities (14%-15%). Side effects of immunotherapy: “itis” (fever, ocular toxicity, lung, colon, rash, many others). These side effects may persist despite cessation of immunotherapy unlike targeted therapies, in which side effects resolve after stopping. Treatment decisions following adverse events depend on how much therapy is delivered prior to the event and the severity of toxicity.   Drug Class Mechanism of action Interferon Antiviral ·   Inhibits protein synthesis ·   Inactivates viral RNA ·   Enhances phagocytic and  cytotoxic mechanisms   Ipilimumab Checkpoint inhibitor ·   IgG1 monoclonal antibody against cytotoxic T-lymphocyte antigen 4   Nivolumab Checkpoint inhibitor ·   Human IgG4 monoclonal antibody against programmed death 1 (PD-1)   Pembrolizumab Checkpoint inhibitor ·   Human IgG4 monoclonal antibody against programmed death 1 (PD-1) Dabrafenib Targeted therapy ·   BRAF inhibitor   Vemurafenib Targeted therapy ·   BRAF inhibitor Trametinib Targeted therapy ·   MEK inhibitor    Show notes by Emily Bryer, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. References Weber J et al. Adjuvant nivolumab versus ipilimumab in resected stage III or IV melanoma. N Engl J Med. 2017;377:1824-35. Eggermont AMM et al. Adjuvant pembrolizumab versus placebo in resected stage III melanoma. N Engl J Med. 2018;378:1789-1801. Long GV et al. Adjuvant dabrafenib plus trametinib in stage III BRAF-mutated melanoma. N Engl J Med. 2017;377:1813-23.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
In this edition, we conclude our 3-part series about having hard conversations with patients as a trainee. This week's case poses the following question: "What would you do if this were your family member?" Ilana Yurkiewicz, MD, Blood & Cancer cohost and producer of the Clinical Correlation segment, is joined by the two residents who have been behind the Blood & Cancer show notes from the beginning, Emily Bryer, DO, and Ronak Mistry, DO, both of the University of Pennsylvania, Philadelphia. David H. Henry, MD, editor in chief of MDedge Hematology-Oncology and the host of Blood & Cancer, joins the podcast to talk about whether multiple myeloma patients with should receive maintenance therapy until progression.  Timestamps: TBD Dr. Henry's on difficult conversations (01:15) This week in Oncology (04:17) Difficult conversations for trainees part III (06:37) Links: This week in Oncology What is the optimal duration of maintenance in myeloma? Ilana Yurkiewicz, MD Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University.  Hard Questions Emily Bryer, DO Ronak Mistry, DO   For more MDedge podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
Hematology/oncology requires clinicians to have some of the most difficult conversations in all of medicine. In part 2 of our 3-part series, we tackle how to talk about ending curative therapy even when the family wants to keep going.  These conversations are hosted by Ilana Yurkiewicz, MD, the host and producer of the Clinical Correlation segment and the author of Hard Questions, a monthly column at MDedge Hematology-Oncology. She is joined by the two residents who have been behind the Blood & Cancer show notes from the beginning, Emily Bryer, DO, and Ronak Mistry, DO, both of the University of Pennsylvania, Philadelphia. David H. Henry, MD, editor in chief of MDedge Hematology-Oncology and the host of Blood & Cancer, also joins the podcast to talk about treatment discontinuation in multiple myeloma. Timestamps: This week in Hematology/Oncology: 04:00 Conversation: 08:00 Links: This Week in Oncology: Study finds no standard for treatment discontinuation in myeloma Ilana Yurkiewicz, MD: Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Hard Questions Emily Bryer, DO Ronak Mistry, DO For more MDedge podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
Hematology/oncology requires clinicians to have some of the most difficult conversations in all of medicine. In this edition, we begin a three-part series about having those conversations.  These conversations will be hosted by Ilana Yurkiewicz, MD, the host and producer of the Clinical Correlation segment and the author of Hard Questions, a monthly column at MDedge Hematology-Oncology. She is joined by the two residents who have been behind Blood & Cancer show notes from the beginning, Emily Bryer, DO, and Ronak Mistry, DO, both of the University of Pennsylvania, Philadelphia. David H. Henry, MD, editor in chief of MDedge Hematology-Oncology and the host of Blood & Cancer, joins the podcast to talk about this week's discussion and a new Food and Drug Administration approval from earlier in September.   Time stamps: Intro (00:05) This Week in Oncology (04:11) Conversation (07:30) Links: This Week in Oncology:  FDA approves pembrolizumab/lenvatinib combo for advanced endometrial carcinoma Ilana Yurkiewicz, MD: Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Hard Questions Emily Bryer, DO Ronak Mistry, DO   For more MDedge podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
 Alok Khorana, MD, of the Cleveland Clinic joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to break down the latest recommendations from the American Society of Clinical Oncology on venous thromboembolism (VTE) prophylaxis in cancer patients. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, shares her answer to a frequent question from cancer patients: What should I eat? This Week in Oncology What is the role of thromboprophylaxis in patients with cancer in the outpatient setting?  Key change in ASCO recommendations: Thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin (LMWH) may be offered to select high-risk outpatients with cancer. Prophylactic anticoagulation should not be given to every patient with malignancy. Khorana score predicts the venous thromboembolism in patients with malignancy. Influenced by type of malignancy, hemoglobin, platelet count, leukocyte count, and BMI. High risk = Khorana score of 2 or higher may be offered prophylaxis. Patients with pancreatic cancer and gastric cancer are particularly coagulopathic. Does the presence of a CNS lesion(s) preclude anticoagulation for a DVT/PE? All CNS lesions have a risk of hemorrhage. A CNS lesion hemorrhage is not significantly greater when anticoagulated Among high-risk cancer patients who undergo surgery, is there a role for postoperative prophylaxis with LMWH? Data show a persistent risk of VTE up to 4 weeks following abdominal/pelvic surgery.   Show notes by Emily Bryer, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   References: Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO Clinical Practice Guideline Update ascopubs.org/doi/pdf/10.1200/JCO.19.01461 Rivaroxaban for thromboprophylaxis in high-risk ambulatory patients with cancer nejm.org/doi/full/10.1056/NEJMoa1814630 Apixaban to prevent venous thromboembolism in patients with cancer nejm.org/doi/full/10.1056/NEJMoa1814468   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
David Fajgenbaum, MD, of the University of Pennsylvania, Philadelphia, is a pioneer in the research of Castleman disease and he’s a patient himself. He joins Blood & Cancer host David Henry, MD, of Pennsylvania Hospital, Philadelphia, to talk about the presentation of Castleman, available treatments, and his own patient journey. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about compassion fatigue among friends and family of cancer patients. This Week in Oncology Time Stamps: This week in Oncology (03:51) Interview (07:24) Clinical Correlation (34:15) Show notes Castleman disease is a group of disorders unified by certain histologic features, including: Atrophic (B-cell depleted) germinal centers with wide mantle zones. Increased number of plasma cells in the interfollicular space. Increased number of blood vessels in the interfollicular space. The disease can be subdivided into unicentric Castleman disease (UCD) or multicentric Castleman disease (MCD), based upon the extent of the lymph node involvement. Multicentric Castleman is further subdivided into HHV8-associated and non HHV8-associated (idiopathic) disease. Determination of HHV-8 status is very important for the selection of the appropriate therapeutic strategy. The presentation of Castleman Disease may be similar to the presentation of lymphomas, including fatigue, night sweats, peripheral edema, pancytopenia, and disseminated lymphadenopathy. The diagnosis depends on the unique histologic appearance after bone marrow biopsy is performed. Patients with Castleman disease often require hospitalization given rapid progression of symptoms due to massive cytokine release. MCD is a rare clinical entity, and to date, only one randomized controlled trial has been published to date (involving siltuximab). Therapeutic options: Unicentric Castleman disease Effectively treated with surgical excision of enlarged lymph node. Multicentric Castleman disease Rituximab (anti-CD20 monoclonal antibody) Has been used off-label as first-line treatment in HIV-positive/HHV-8-positive MCD, alone or in combination with conventional chemotherapeutics. Siltuximab (anti-IL-6 monoclonal antibody) Currently the only approved treatment of idiopathic MCD in the United States. Tocilizumab (humanized IL-6 receptor antagonist) Approved for treatment of idiopathic MCD in Japan. Sirolimus (mTOR pathway inhibition) Under investigation at the University of Pennsylvania for treatment of patients who have been refractory to IL-6 blockade. Bortezomib (selective proteasome inhibitor) and Anakinra (IL-1 receptor antagonist) A small number of case reports suggest these may be used in MCD.   Dr. Fajgenbaum can be reached at davidfa@pennmedicine.upenn.edu. More information about Castleman disease can be found at www.cdcn.org.  Dr. Fajgenbaum’s memoir is Chasing My Cure: A Doctor’s Race to Turn Hope into Action Show notes by Sugandha Landy, MD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz    
  David L. Streiner, PhD, of McMaster University, Hamilton, Ont., and the University of Toronto, joins Blood & Cancer host David Henry, MD, of Pennsylvania Hospital, Philadelphia, to talk about meta-analyses and what they really tell us about the evidence for treatment. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about when a second or third opinion can be detrimental in aggressive cancer. This Week in Oncology Show notes Meta-analysis: A systematic, thorough review of the literature, extraction of the effect sizes, and mathematical combination of effect sizes to produce an overall estimate. Analyses (both negative and positive trials) with larger sample sizes get more weight than smaller studies do.  Example: Erythropoiesis-stimulating agents in oncology: A study-level meta-analysis of survival and other safety outcomes Br J Cancer. 2010; 102(2):301-15. Analyzed 60 studies, including unpublished works. Conclusion of the meta-analysis: Erythropoiesis-stimulating agents had no significant effect on the outcome of survival. Forest plots: Null hypothesis = odds ratio of 1 means no difference between the two groups. Squares on the right of the line favor control group. Squares on the left of the line favor treatment group. The size of the square corresponds with the sample size. Each meta-analysis is to be evaluated as an estimate of truth, but not truth itself. Show notes by Emily Bryer, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
GI malignancy case review

GI malignancy case review

2019-08-2900:31:07

Daniel G. Haller, MD, of the University of Pennsylvania, Philadelphia, joins Blood & Cancer host David H. Henry, MD, also of the University of Pennsylvania, to discuss two real-world gastrointestinal cancer cases and how the latest research should influence the approach to care. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University talks about pressure from patients to overtreat indolent cancer. This week in Oncology: Perceived discrimination linked to delay in ovarian cancer diagnosis for black women Perceived everyday discrimination was associated with an extended duration between symptom onset and cancer diagnosis in black women with ovarian cancer. Time Stamps: This week in Oncology (04:47) Interview with Dr. Haller (07:27) Clinical Correlation (26:20) Show Notes Patient case #1: Patient presents with a T2 tumor with right-sided colon cancer with invasion of a large right vessel. What is the best management?  The IDEA collaboration: Large analysis to evaluate CAPOX vs. FOLFOX therapy for colorectal cancer and to determine 3 months vs. 6 months of therapy. Researchers at the 2019 American Society of Clinical Oncology annual meeting presented an evaluation of the treatments in stage II colon cancer with high-risk features (Abstract 3501). Definition of high risk: T4, inadequate nodal harvest, poorly differentiated, obstruction, perforation or vascular/perineural invasion. Difficult for pathologists to diagnose T4 disease. The definition of high-risk disease was slightly different in each individual trial. T stage makes the most difference of all. Overall data: Difference in survival is 3% between 3 months and 6 months of therapy. Results by regimen: CAPOX: 3 months vs. 6 months, the difference in survival is almost identical. FOLFOX: 3 months vs. 6 months, difference in survival was 7%, with 6 months being superior. Link: asco.org/239/AbstView_239_257383.html Refresher on grading colorectal cancers: net/cancer-types/colorectal-cancer/stages Patient case #2: A 38-year old woman with past medical history of diverticulitis presents with left lower quadrant pain and is treated with antibiotics but does not improve. She was referred for colonoscopy, which reveals sigmoid polyp; pathology shows moderately differentiated adenocarcinoma. A CT scan is performed, which reveals a lesion that is transmural, circumferential in the sigmoid, and requires surgery. Sigmoid is colectomy performed for a large tumor and serosal and pericolic and immediately adjacent retroperitoneal soft tissue is noted. Other notable features included lymphovascular invasion but no metastases. Genetic testing shows RAS/BRAF negative and MMR analysis notes PMS2 negative.  Concern for Lynch syndrome given right-sided disease, female, large tumor; therefore, genetic testing for Lynch syndrome is recommended. This is important because patient requires more frequent colonoscopies. Work with surgeons to recommend keeping clips in place to minimize area that gets radiation. Approach to treatment: Dr. Haller recommends the “sandwich approach,” in which the patient receives chemotherapy, then radiation, then more chemotherapy. FOLFOX or CAPOX are both chemotherapy options.   Show notes by Ronak Mistry, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz      
  William J. Gradishar, MD, of Feinberg School of Medicine and Northwestern Medicine in Chicago, chats with David H. Henry, MD, host of Blood & Cancer, to review some of the top breast cancer research presented at the 2019 annual meeting of the American Society of Clinical Oncology. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about dealing with help-seeking and help-rejecting patients.   Show notes This episode discusses three randomized, controlled phase 3 trials that were presented at ASCO 2019:  KRISTINE trial (abstract 500) Design: Patients with HER2-positive breast cancer were randomized to receive either neoadjuvant trastuzumab, pertuzumab, and chemotherapy (docetaxel, carboplatin) vs. trastuzumab emtansine plus pertuzumab. Primary endpoint: Pathological complete response rate. Secondary endpoints: Toxicity, event-free survival, invasive disease-free survival. Conclusion: Docetaxel, carboplatin, and trastuzumab plus pertuzumab resulted in a higher rate of pathological complete response than did trastuzumab emtansine plus pertuzumab, but was associated with more serious adverse events. PREDIX trial (abstract 501) Design: Patients with HER2 positive and hormone receptor positive breast cancer were randomized to receive either neoadjuvant trastuzumab emtansine monotherapy vs. docetaxel, trastuzumab, and pertuzumab. Primary endpoint: Pathological complete response rate. Secondary endpoints: Toxicity and quality of life. Conclusions: Trastuzumab emtansine monotherapy was better tolerated while maintaining comparable PCR rate as the group which received docetaxel, trastuzumab, and pertuzumab.  TAILORx trial (abstract 503) Design: Patients with node-negative, estrogen receptor–positive breast cancer with an Oncotype DX recurrence score of 11-25 were randomized to receive either hormone therapy alone or hormone therapy together with combination chemotherapy. Primary endpoint: Rate of distant recurrence at 9 years.  Conclusions: There was no benefit from chemotherapy for younger women (aged 50 years or younger) with a recurrence score of 16-20 and at low risk clinically (small tumor size and favorable histologic grade). Those age younger than age 50 years with a score of 16-20, but high risk clinically, may benefit from chemotherapy. Much of the benefit derived from chemotherapy was because of ovarian suppression. Using the recurrence score in combination with clinical risk stratification allows clinicians to identify more young women who can be spared chemotherapy, and more young women who may benefit from antiestrogen therapy.   Show notes by Sugandha Landy, MD, a resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   References J Clin Oncol 37. 2019 May 20 (suppl; abstr 500). doi: 10.1200/JCO.2019.37.15_suppl.500. J Clin Oncol 37. 2019 May 20 (suppl; abstr 501). doi: 10.1200/JCO.2019.37.15_suppl.501. J Clin Oncol 37. 2019 May 20 (suppl; abstr 503). doi: 10.1200/JCO.2019.37.15_suppl.503. Lancet Oncol. 2018 Jan;19(1):115-26. N Engl J Med. 2019 Jun 20;380:2395-405.    For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
Geriatric oncology

Geriatric oncology

2019-08-1500:35:17

  David Cella, PhD, of Northwestern University in Chicago, joins Blood & Cancer as the guest host for a conversation with Supriya Mohile, MD, MS, of the University of Rochester in N.Y., on geriatric oncology and the best tools to assess the fitness of older patients with cancer. In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about social support and what happens when there isn’t a supportive family member at the bedside. Show notes What is “geriatric oncology?” The geriatrics population is traditionally defined as people aged 65 years and older. Geriatric medicine focuses on patient function and interventions that improve resilience, such as mobility, physical functional status, cognitive function, aging-related issues, and polypharmacy. Geriatric oncology integrates these principles into cancer treatment for the elderly. Clinical trials tend to exclude older, more frail patients in their study population, making it harder to apply the outcomes of trials to the geriatric population. Choosing an appropriate regimen and dose is harder for older patients since toxicity and dosage data are obtained from a more fit population. The general rule is to “start low and go slow” for elderly patients. In frail patients, oncologists should reconsider treatment altogether because of the implications on functional status. Assessment tools for elderly patients Geriatric assessment: A validated series of tests based on a survey that assesses categories such as function and quality of life, as well as objective findings, such as cognition and physical performance. It is a better way to determine health status for elderly patients than are the standard ECOG ratings. ASCO Guidelines in Geriatric Assessment Cancer and Aging Research Group: A community of researchers who are working collaboratively to design and implement clinical trials to improve cancer care in older adults. Show notes by Ronak Mistry, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
The pitfalls of P values

The pitfalls of P values

2019-08-0800:31:14

David L. Streiner, PhD, of McMaster University, Hamilton, Ont., and the University of Toronto, joins Blood & Cancer host David Henry, MD, of Pennsylvania Hospital, Philadelphia, to explain what P values actually measure and how they both help and hinder the interpretation of clinical research findings. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, explores how quickly cancer can turn into bankruptcy. Show notes In statistics, P value is null hypothesis significance testing. The P value assesses the following: If the null hypothesis (i.e., there is no difference) is true, what is the probability that we could get data that is extreme? What are researchers doing when they test this way? Given the null hypothesis (i.e., we are assuming data is from chance alone), what is the probability that the data are actually true? What do researchers actually want to be able to do? Given the data, what is the probability of the null hypothesis (i.e., random chance alone is responsible for the difference)? The P value is affected by sample size; a smaller sample is more easily influenced by variable data and can result in outcomes that are not statistically significant. Large sample sizes are affected less by variables. It is important to differentiate what is statistically significant from what is clinically significant. Remember, P less than .05 is an arbitrary number. Do not let a P value deter use of a therapy that may show clinical benefit. Show notes by Ronak Mistry, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
Edward S. Kim, MD, of Levine Cancer Institute at Atrium Health in Charlotte, N.C., chats with David H. Henry, MD, host of Blood & Cancer, about how to perform clinical trials in the community oncology setting. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, discusses a byproduct of our fragmented health care system – patients having to hear the same bad news repeated over and over. Show notes  Only 3%-4% of adult oncology patients are enrolled in clinical trials. Most patients diagnosed with cancer are seen in community settings (as opposed to academic centers). Oncologists in the community setting face significant obstacles to enrolling their patients in clinical trials: Communication between academic and community centers often is lacking, especially in more rural areas of the country. Community-based oncologists usually are not compensated for time spent on research or academic work. Treatment pathways used by many oncologists may not offer any information regarding clinical trials. The traditional infrastructure of a community practice may not have the necessary experts to facilitate clinical trial participation. Community oncologists may not feel comfortable talking to their patients about a novel drug of which they have little knowledge. How can community oncologists facilitate participation in clinical trials? There must be a cultural change, starting with the organization’s leadership. A study coordinator is crucial. Data, finance, and regulatory individuals are likely required. Coordination with pharmacy and pathology usually is necessary. Electronically Accessible Pathways (EAPathways) is a tool developed by Dr. Kim’s team. It is available and allows any oncologist to input a patient’s information to determine if there is an appropriate clinical trial available. Show notes by Sugandha Landy, MD, a resident in the department of internal medicine, University of Pennsylvania, Philadelphia Dr. Kim can be reached at Edward.Kim@atriumhealth.org   Additional reading Patronik KE and ES Kim. A novel clinical pathways approach to delivering regional-based clinical trials and patient care in a hybrid academic- community-based system. J Clin Pathways. 2018 May;4(4):52-5. Ersek JL et al. Implementing precision medicine programs and clinical trials in the community-based oncology practice: Barriers and best practices. Am Soc Clin Oncol Educ Book. 2018 May 23:38:188-96.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
Ginah Nightingale, PharmD, of the Jefferson College of Pharmacy at Thomas Jefferson University in Philadelphia chats with David H. Henry, MD, host of Blood & Cancer, about the definition of polypharmacy and the challenges it poses in treating older cancer patients. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about the waiting that cancer patients face. Show notes Older adults comprise about 15% of the total population but account for more than 33% of prescription drug use. Polypharmacy can be defined as taking five or more medications (prescription and nonprescription), as well as being on medications that have adverse effects in older adults. Older adults are at increased risk for adverse effects from polypharmacy for multiple reasons, including multiple comorbidities and altered drug metabolism. In a study by Nightingale et al., 61% of patients already had a major drug-drug interaction on their medication list prior to initiation of cancer therapy. In a study by Sharma et al., 22% of patients were taking proton pump inhibitors concurrently with tyrosine kinase inhibitors, an interaction that was associated with increased risk of death at 90 days and 1 year. Patients who receive medications from multiple pharmacies, such as a specialty pharmacy for oncologic drugs, are at increased risk of polypharmacy errors. Tools to screen for polypharmacy include: Beers criteria by American Geriatrics Society STOPP/START criteria (commonly used in Europe) Medication appropriateness index Considerations such as patient’s life expectancy and quality-of-life goals should be taken into account when deciding which medications are necessary and what may be deprescribed. Clinicians should encourage patients to bring in all medications to every doctor’s visit, and certainly at the time of initiation of cancer treatment. Show notes by Sugandha Landy, MD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   Additional reading American Geriatrics Society 2019 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674-94. O'Mahony Denis et al. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing. 2015 Mar;44(2):213-8. Nightingale G et al. Evaluation of a pharmacist-led medication assessment used to identify prevalence of and associations with polypharmacy and potentially inappropriate medication use among ambulatory senior adults with cancer. J Clin Oncol. 2015 May 1;33(13):1453-9. Sharma M et al. The concomitant use of tyrosine kinase inhibitors and proton pump inhibitors: Prevalence, predictors, and impact on survival and discontinuation of therapy in older adults with cancer. Cancer. 2019 Apr 1;125(7):1155-62.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
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