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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.
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Ilana Yurkiewicz, MD, recorded dozens of Clinical Correlation segments for Blood & Cancer for more than a year. She also hosted a three-part series on difficult conversations that trainees have with their patients. In this episode, we revisit the best of Dr. Yurkiewicz.   'How long do I have left?' 02:59 Anxiety 17:02 Optimism Bias 20:21 Social Support 23:51 Family Dynamics 26:07 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
EHA25 highlights: EHA President John Gribben talks AML, myeloma, polycythemia vera, and COVID-19 What were the late-breaking and practice-changing presentations at EHA25 Virtual? John Gribben, MD, DSc, president of the European Hematology Association, highlighted some of them in this podcast. Dr. Gribben and host David H. Henry, MD, discussed presentations on acute myeloid leukemia (AML), multiple myeloma, polycythemia vera (PV), and COVID-19. Videos of these and other presentations will be available on the EHA25 website until Oct. 15.  Randomized, double-blind, placebo-controlled study of venetoclax with azacitidine vs. azacitidine in treatment-naïve patients with acute myeloid leukemia ineligible for intensive therapy—VIALE-A: Adding venetoclax to azacitidine improved survival, response, and transfusion independence in older patients with treatment-naïve AML.  Older AML patients have seen “very little progress” in outcomes for decades, but advances such as these are “really moving the field,” Dr. Gribben said.  Abstract LB2601: https://rb.gy/fou9jp  Presentation: https://rb.gy/mmwn6s    Phase 2 randomized trial comparing ropeginterferon versus phlebotomy in low-risk patients with polycythemia vera. Results of the pre-planned interim analysis: Ropeginterferon was safe and more effective than phlebotomy for keeping hematocrit on target in patients with low-risk PV.  These findings suggest ropeginterferon is a viable option for PV patients, but “old-fashioned phlebotomy can also be quite efficient,” Dr. Gribben said. Physicians will have to weigh the risks and benefits, including cost-effectiveness, of each treatment, he added. Abstract LB2602: https://rb.gy/uicnmo Presentation: https://rb.gy/sj60ia Isatuximab plus carfilzomib and dexamethasone vs carfilzomib and dexamethasone in relapsed/refractory multiple myeloma (IKEMA): Interim analysis of a phase 3, randomized, open-label study: Adding isatuximab to carfilzomib-dexamethasone improved progression-free survival and time to next treatment. Overall survival data are not mature. The study was stopped early because the primary endpoint was met, as isatuximab “clearly demonstrated superiority,” Dr. Gribben noted. It isn’t clear how isatuximab stacks up against daratumumab, but these results suggest “people now have another CD38 antibody to consider as part of their armamentarium,” Dr. Gribben said.   Abstract LB2603: https://rb.gy/gmxcgk  Presentation: https://rb.gy/v209ol Endotheliopathy in COVID-19 associated coagulopathy   This study showed “very clear evidence” of endothelial damage contributing to coagulopathy among severely ill patients with COVID-19, Dr. Gribben said.  Endothelial cell and platelet markers were elevated in COVID patients who required intensive care, and soluble thrombomodulin was linked to survival.  These findings prompted the decision to give all COVID patients aspirin.  Abstract LB2605: https://rb.gy/sdc9dv  Presentation: https://rb.gy/nxvpxj   Iron metabolism in health and disease (Plenary I)  This presentation suggested inflammation-induced hypoferremia can predict disease severity in COVID-19 patients. The presenter posited that iron accumulation in macrophages may increase inflammation and contribute to organ damage in COVID patients.  “You can imagine a whole cascade of events that this virus triggers off,” Dr. Gribben said. Presentation: https://rb.gy/5lz3d6   Disclosures:   Dr. Gribben reported relationships with Janssen, Celgene, Bristol Myers Squibb, AstraZeneca, AbbVie, Roche, Genentech, and Acerta Pharma.   Dr. Henry reported having no disclosures relevant to this episode.    * * * 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  
The Food and Drug Administration has approved dozens of drugs for new hematology/oncology indications this year. Host David Henry, MD, was joined by David Mintzer, MD, and other colleagues at Penn Medicine in Philadelphia – Justine Cohen, DO, and Ingrid Kohut, DO – to discuss some of these approvals. Dr. Mintzer reviewed: The “game-changing” approval of niraparib (Zejula) in advanced ovarian, fallopian tube, or primary peritoneal cancer. The “exciting” approval of sacituzumab govitecan-hziy (Trodelvy) in metastatic triple-negative breast cancer. The “COVID-relevant” approval of a new dosing regimen for pembrolizumab (Keytruda) – 400 mg every 6 weeks – across all approved adult indications. The “niche” approval of mitomycin (Jelmyto) for adults with low-grade upper tract urothelial cancer. And several other approvals the FDA granted this year. Details on all approvals are available on the FDA website. *  *  *   Disclosures: Dr. Henry and all guests reported having no relevant disclosures.   *  *  *   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  
What were the practice-changing studies presented at the 2020 ASCO Annual Meeting? Podcast host David H. Henry, MD, and retired oncologist Alan P. Lyss, MD, reviewed 12 studies and assessed their potential impact on treatment.  Breast cancer Three-year follow-up of neoadjuvant chemotherapy with or without anthracyclines in the presence of dual HER2-blockade for HER2-positive breast cancer (TRAIN-2): A randomized phase III trial. (Abstract 501) The addition of anthracyclines did not improve event-free or overall survival. The results suggest patients can avoid the toxicities of anthracycline regimens without compromising efficacy, Dr. Henry said. KEYNOTE-355: Randomized, double-blind, phase III study of pembrolizumab + chemotherapy versus placebo + chemotherapy for previously untreated locally recurrent inoperable or metastatic triple-negative breast cancer. (Abstract 1000) Pembrolizumab improved responses, particularly in patients with higher PD-L1 expression. Dr. Lyss noted that pembrolizumab was combined with a “broad range” of chemotherapy regimens in this study.   A randomized phase III trial of systemic therapy plus early local therapy versus systemic therapy alone in women with de novo stage IV breast cancer: A trial of the ECOG-ACRIN Research Group (E2108). (Abstract LBA2) Early local therapy did not improve disease-free survival or overall survival. “We probably should not be recommending planned treatment for the intact primary tumor in most women who have stage IV breast cancer,” Dr. Lyss said. Bladder cancer Maintenance avelumab + best supportive care (BSC) versus BSC alone after platinum-based first-line (1L) chemotherapy in advanced urothelial carcinoma (UC): JAVELIN Bladder 100 phase III interim analysis. (Abstract LBA1) Avelumab maintenance prolonged overall survival, although 12% of patients discontinued the treatment due to toxicity. Because avelumab “meaningfully prolongs overall survival … using it upfront makes a lot of sense,” Dr. Lyss said. Colorectal cancer Pembrolizumab versus chemotherapy for microsatellite instability-high/mismatch repair deficient metastatic colorectal cancer: The phase 3 KEYNOTE-177 study. (Abstract LBA4) Pembrolizumab improved responses and progression-free survival. All patients with colorectal cancer should be tested for microsatellite instability-high status “because these results really do influence practice immediately,” Dr. Lyss said. He suggested that pembrolizumab should probably be used as first-line treatment for these patients even though overall survival results are not yet available.   Short-course radiotherapy followed by chemotherapy before TME in locally advanced rectal cancer: The randomized RAPIDO trial. (Abstract 4006) Short-course radiotherapy followed by consolidative chemotherapy and surgery significantly reduced the rate of treatment failure. Dr. Lyss called the pathologic complete response rate “impressive” and said it may contribute to a higher rate of rectal preservation.   A randomized phase II/III trial comparing hepatectomy followed by mFOLFOX6 with hepatectomy alone for liver metastasis from colorectal cancer: JCOG0603 study. (Abstract 4005) There was no improvement in overall survival with mFOLFOX6. “The take-home to me … is this is probably not a necessary strategy and certainly not standard of care,” Dr. Henry said.   Hodgkin lymphoma KEYNOTE-204: Randomized, open-label, phase III study of pembrolizumab (pembro) versus brentuximab vedotin (BV) in relapsed or refractory classic Hodgkin lymphoma (R/R cHL). (Abstract 8005) Pembrolizumab improved progression-free survival. Dr. Henry marveled that pembrolizumab bested brentuximab vedotin, which previously produced impressive results in patients with relapsed/refractory Hodgkin lymphoma. Lung cancer Nivolumab + ipilimumab versus platinum-doublet chemotherapy as first-line treatment for advanced non-small cell lung cancer: Three-year update from CheckMate 227 Part 1. (Abstract 9500) Nivolumab plus ipilimumab improved overall survival but increased toxicity and treatment discontinuation. The combination is “not for the faint hearted” but is appropriate for certain patients, Dr. Lyss said, noting there is “room for clinical judgement.”   Osimertinib as adjuvant therapy in patients (pts) with stage IB–IIIA EGFR mutation positive (EGFRm) NSCLC after complete tumor resection: ADAURA. (Abstract LBA5) Osimertinib improved disease-free survival compared with placebo. It isn’t clear how osimertinib will impact overall survival, but “we should be using this drug” once it’s approved, Dr. Lyss said.   Smoking cessation (SC) and lung cancer (LC) outcomes: A survival benefit for recent-quitters? A pooled analysis of 34,649 International Lung Cancer Consortium (ILCCO) patients. (Abstract 1512) Quitting smoking can improve overall survival in lung cancer patients, even if they quit as little as 2 years prior to diagnosis. “Somewhat counterintuitively, convincing patients to quit smoking at any point in their trajectory, even just prior to their diagnosis, seems to make a difference in survival,” Dr. Lyss said.   Ovarian cancer Final overall survival (OS) results from SOLO2/ENGOT-ov21: A phase III trial assessing maintenance olaparib in patients (pts) with platinum-sensitive, relapsed ovarian cancer and a BRCA mutation. (Abstract 6002) Olaparib maintenance improved overall survival and time to next treatment. Significant benefits were seen in the olaparib arm in spite of a high rate of crossover, Dr. Henry noted. *  *  *   Disclosures: Dr. Henry, of Penn Medicine in Philadelphia, reported having no financial disclosures relevant to this episode. Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. He is a columnist for MDedge Hematology/Oncology. He has no other conflicts of interest. *  *  *   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
Jack West, MD, joins the podcast to discuss how he chooses first-line treatment in new patients with non–small cell lung cancer (NSCLC). 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 also explores how the COVID-19 pandemic influences treatment approaches, the usefulness of liquid biopsy, and how he weighs the potentially higher risk for COVID-19 complications from checkpoint inhibitors.   Check out Dr. West’s last two appearances on the podcast: https://www.mdedge.com/podcasts/blood-cancer/immunotherapy-lung-cancer-dr-jack-west-part-1 https://www.mdedge.com/podcasts/blood-cancer/immunotherapy-lung-cancer-dr-jack-west-part-2   Disclosures: Dr. Henry reported having no financial disclosures relevant to this episode. Dr. West has a full list of his financial disclosures here. *  *  *   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
David H. Henry, MD, answers the question, "Would you choose oncology again?" This question was asked of oncologists surveyed for the Medscape Oncologist Compensation Report 2020, and 96% of oncologists said they would still choose oncology as their specialty. Later, William J. Gradishar, MD, of Northwestern University in Chicago, joined Dr. Henry to discuss recent developments in breast cancer. Dr. Gradishar reviewed three trials presented at the 2019 San Antonio Breast Cancer Symposium (SABCS), two of which will be updated at the ASCO Annual Meeting. *  *  *   SABCS highlights HER2CLIMB trial: This trial led to the recent U.S. approval of tucatinib in combination with trastuzumab and capecitabine. The phase 2 trial enrolled patients with heavily pretreated, HER2-positive, metastatic breast cancer (N Engl J Med. 2020 Feb 13; 382:597-609). Patients who received tucatinib plus trastuzumab and capecitabine had superior progression-free and overall survival, compared with patients who received placebo plus trastuzumab and capecitabine. Tucatinib even improved outcomes in patients with brain metastasis, Dr. Gradishar noted. Additional results from HER2CLIMB are scheduled to be presented at ASCO in Abstract 1005. DESTINY-BREAST01 trial: This trial led to the U.S. approval of trastuzumab deruxtecan. Trastuzumab deruxtecan produced durable responses and a median progression-free survival of 16.4 months in patients with HER2-positive, metastatic breast cancer who had previously received trastuzumab emtansine (N Engl J Med 2020; 382:610-621). A key side effect of trastuzumab deruxtecan is interstitial lung disease, which led to deaths in the trial and a black box warning for the antibody-drug conjugate. A subgroup analysis of data from DESTINY-BREAST01 is scheduled to be presented at ASCO in Abstract 1036. KEYNOTE-522 trial: The phase 3 trial enrolled patients with early triple-negative breast cancer (N Engl J Med 2020; 382:810-821). The rate of pathologic complete response (pCR) was significantly higher in patients who received pembrolizumab plus neoadjuvant chemotherapy than in patients who received placebo plus neoadjuvant chemotherapy. Although it is clear that pembrolizumab improves pCR, it isn’t clear if the checkpoint inhibitor will improve long-term outcomes, Dr. Gradishar said. Disclosures: Dr. Henry reported having no financial disclosures relevant to this episode. Dr. Gradishar reported financial relationships with AstraZeneca, Celltrion, Genentech, MacroGenics, Merck, Pfizer, and Seattle Genetics. *  *  * 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    
Adam C. Cuker, MD, joins host David H. Henry, MD, to discuss recent findings regarding coagulation in COVID-19 patients. Both Dr. Cuker and Dr. Henry both practice at the Hospital of the University of Pennsylvania in Philadelphia. Dr. Cuker cited data suggesting at least 25%-30% of patients with COVID-19 develop venous thromboembolism (VTE), despite receiving prophylactic anticoagulation. Furthermore, COVID-19 patients have presented with “lots of different thrombotic manifestations,” he said. This includes stroke and “COVID toes syndrome,” a condition in which patients present with ischemic toes, which appears to have a thromboembolic etiology. Dr. Cuker suggested that all three aspects of Virchow’s triad may be at play in patients with COVID-19 who have thrombotic manifestations, including: Circulatory stasis (in patients who are immobilized/sedated/prone/paralyzed). Hypercoagulability (inflammation, high levels of factor VIII and fibrinogen, neutrophil extracellular traps). Endothelial injury (SARS-CoV-2 may infect endothelial cells via ACE2). Dr. Cuker notes that high D-dimer correlates with disease severity and prognosis in COVID-19 patients. He also compares COVID-19 to heparin-induced thrombocytopenia (HIT), noting that both are associated with venous and arterial thromboses. And, like HIT patients, those with COVID-19 may require therapeutic-intensity anticoagulation to prevent clots. Dr. Cuker says his hospital’s recommendations for anticoagulation in COVID-19 patients are as follows: Stable hospitalized patients should receive standard-intensity prophylaxis. ICU patients should receive intermediate- or therapeutic-intensity anticoagulation (at the discretion of the provider). On discharge, patients should receive low-dose rivaroxaban (Xarelto) at 10 mg daily for 30 days as prophylaxis. A nonhospitalized patient who has no risk factors for thrombotic events should not receive thromboprophylaxis. Dr. Cuker also discusses two recent publications on thrombosis and anticoagulation in COVID-19 patients. In one study, thrombotic events occurred in 31% of COVID-19 patients admitted to the ICU at three Dutch hospitals (Thromb Res. 2020 Apr 10. pii: S0049-3848(20)30120-1). Another study suggested that systemic anticoagulation may improve outcomes of patients hospitalized with COVID-19 (J Am Coll Cardiol. 2020 May 5. pii: S0735-1097(20)35218-9). Show notes by Emily Bryer, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. Disclosures: Dr. Henry has no financial disclosures relevant to this episode. Dr. Cuker has served as a consultant for Synergy CRO. His institution has received research support on his behalf from Alexion, Bayer, Pfizer, Novo Nordisk, Sanofi, Spark, and Takeda. *  *  *  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      
In this episode, Matthew Watto, MD, an internist at Pennsylvania Hospital in Philadelphia, tells host David H. Henry, MD, also of Pennsylvania Hospital, how the COVID-19 pandemic has affected him personally and professionally. Dr. Watto recounts how COVID-19 has impacted patient volume, shifts, teaching, and interactions between patients and staff. Dr. Watto also discusses his internal medicine podcast, The Curbsiders, which, he says, provides listeners with “clinical pearls, practice-changing knowledge, and bad puns.” Disclosures: Dr. Henry has no financial disclosures relevant to this episode. Dr. Watto has no financial disclosures relevant to this episode. *  *  *  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
How should oncologists be treating genitourinary malignancies during the COVID-19 pandemic? Aly-Khan A. Lalani, MD, of McMaster University in Hamilton, Ontario, and colleagues recently published recommendations that help answer that question (Can Urol Assoc J. 2020 May;14[5]:e154-8). In this episode, Dr. Lalani reviews some of these recommendations with podcast host David H. Henry, MD, of Pennsylvania Hospital in Philadelphia. The pair discuss when and how to use androgen receptor axis-targeted therapies and radium-223 in metastatic prostate cancer, platinum-based chemotherapy in advanced urothelial carcinoma, and checkpoint inhibitors in patients with urothelial carcinoma or renal cell carcinoma. *  *  *   Disclosures: Dr. Henry reported having no financial disclosures relevant to this episode. Dr. Lalani has relationships with Astellas Pharma, Bayer, Bristol-Myers Squibb, Merck, Novartis, Pfizer, Roche/Genentech, TerSera, AbbVie, Eisai, Ipsen, and Janssen. *  *  *   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
The American Society of Clinical Oncology is gearing up for its first-ever virtual meeting at the end of May 2020. ASCO’s president Howard A. “Skip” Burris, III, MD, joins David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to explain how the virtual meeting will work, from releasing research to earning continuing medical education credits. Dr. Burris also explores how the society is responding to COVID-19. Later in the podcast, Bernard A. Mason, MD, an oncologist with Pennsylvania Hospital and the University of Pennsylvania, both in Philadelphia, is back with some bonus technology tips for taking notes and syncing them across devices, sharing large files, and best practices for backing up files. Disclosures: Dr. Henry reported having no financial disclosures relevant to this episode. Dr. Burris has a full list of his financial disclosures here. Dr. Mason reported having no financial disclosures relevant to this episode. *  *  *  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
Oncologists are now weighing the benefits of treating cancer patients against the risk of exposing them to SARS-CoV-2. David Kerr, MD, DSc, of University of Oxford (England) talks with podcast host David H. Henry, MD, of Pennsylvania Hospital in Philadelphia, about how to treat colorectal cancer patients in the COVID-19 era. Dr. Kerr cowrote an article on MDedge Hematology/Oncology that outlined recommendations for treating colorectal cancer patients during the pandemic. In this episode, Dr. Henry and Dr. Kerr review those recommendations and compare notes on U.K. and U.S. practices. Disclosures: Dr. Henry reported having no financial disclosures relevant to this episode. Dr. Kerr has founded three university spin-out companies: COBRA Therapeutics, Celleron Therapeutics, and Oxford Cancer Biomarkers. *  *  *   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  
How are community oncologists adapting to the COVID-19 pandemic? Podcast host David H. Henry, MD, of Pennsylvania Hospital in Philadelphia, explores this question with Matthew Lonergan, MD, of Willamette Valley Cancer Institute (WVCI) and Research Center in Eugene, Ore. Dr. Lonergan explains how WVCI is attempting to minimize staff exposure to COVID-19, how physicians there are dealing with the transition to telemedicine, and how a lack of resources has affected WVCI. Dr. Lonergan and Dr. Henry also discuss how the COVID-19 pandemic has changed research, tumor boards, and other meetings. And the pair compare the response to the current pandemic with the response to HIV and the Spanish flu. Disclosures: Dr. Henry reported having no financial disclosures relevant to this episode. Dr. Lonergan reported having no financial disclosures relevant to this episode. *  *  *  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 the “new normal” of treating cancer patients during COVID-19, when do you decide to start treatment or pause it? Narjust Duma, MD, a thoracic oncologist at the University of Wisconsin, Madison, shares how she makes those decisions in partnership with her lung cancer patients and how the discussions are complicated by the fear and uncertainty around the pandemic. Later in the podcast, Dr. Duma and podcast host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, explore how telehealth changes patient encounters, use of liquid biopsies to keep patients out of the hospital, and the importance of checking in with mentees. Disclosures Dr. Henry reported having no financial disclosures relevant to this episode. Dr. Duma reported having no financial disclosures relevant to this episode. *   *   *   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
As the nation’s health care system braces for COVID-19 cases, physicians who’ve faced the pandemic first have critical lessons for everyone. In this bonus episode, two Seattle-area critical care leaders explain how their medical centers are preparing for and responding to their region’s early outbreaks. And they share some creative approaches that are uniting Seattle’s critical care departments.
Zainab Shahid, MD, medical director of bone marrow transplant infectious diseases at the Levine Cancer Institute/Atrium Health in Charlotte, N.C., breaks down when cancer patients should seek testing for COVID-19 and how they should be treated. Dr. Shahid also compares notes with Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital in Philadelphia, on how the COVID-19 pandemic has changed the world of medical education. In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, celebrates National Doctors Day amid the COVID-19 pandemic. Topics covered in this podcast: How the education of trainees as changed. Use of telehealth screening and visits. COVID-19 case volume and when oncology patients should seek testing. Which patients should be considered immunocompromised. *   *   *   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
Susan Dent, MD, codirector of the cardio-oncology program at Duke University in Durham, N.C., reflects on virtual grand rounds, telehealth, the screening of patients before clinic visits, and other new realities of cancer care in the age of COVID-19. Dr. Dent also discusses the importance of assessing breast cancer patients for cardiotoxicity. In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about the importance of advance directives. *  *  *   Cardiotoxicity in breast cancer treatment HER2 drugs (such as trastuzumab) and conjugates If given appropriately, these drugs have limited cardiotoxicity. The mechanism of cardiotoxicity is a “stunning of the heart.” If there is a significant drop in left ventricular ejection fraction, hold the drug. When problems arise, they tend to occur early on. Important to assess baseline risk factors. Older individuals with underlying hypertension, diabetes, and other conditions need monitoring. Anthracyclines The appropriate/safe dose of anthracyclines may be different for each person, based on risk factors such as age and underlying conditions. Assess patients at baseline using cardiac imaging and biomarkers, and risk factors. If no symptoms of cardiotoxicity, reassess 6-12 months after treatment. If a patient has poorly controlled hypertension or diabetes, those factors should be better managed to minimize the risk from anthracyclines. Liposomal anthracyclines These formulations are less cardiotoxic, but they have not been widely adopted in breast cancer. Immuno-oncology antibodies Myocarditis is one of many side effects seen with immunotherapy. It’s not a common side effect (about 1% or less), but when it does occur, it has a 50% fatality rate. Have a high level of suspicion for myocarditis if a patient on immunotherapy presents with shortness of breath and chest pain. *   *   *   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
David Henry, MD, welcomes Bernard A. Mason, MD, to discuss Dr. Mason's favorite digital tools for working as a physician in part 1 of 2. Dr. Mason is an oncologist with the Pennsylvania Hospital and the University of Pennsylvania, both in Philadelphia.  Dr. Mason explains the actual benefits for doctors and health care providers for popular apps and services from storage to maps. He and Dr. Henry explore the following: One drive Google Drive Google Photos Google Maps Offline HERE WeGo This week's installment of Clinical Correlation, Ilana Yurkiewicz, MD, poses a complicated question about oncologist-patient relationships: Do they ever actually end? *  *  *   For more MDedge Podcasts, go to https://www.mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry, MD, on Twitter: @davidhenrymd Ilana Yurkiewicz, MD, on Twitter: @ilanayurkiewicz
There’s an art to taking a thorough bleeding history. In this episode, Adam Cuker, MD, director of the Hemophilia and Thrombosis Center at the University of Pennsylvania, Philadelphia, shares the most important questions to ask and the challenges in assessing risk in patients about to undergo surgery and those with active bleeding. In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about delivering good news to patients.    Practice points: Always take a thorough bleeding history. Ask patients about bleeding from head to toe. Even if the basic laboratory evaluation is normal, the patient may still have a bleeding disorder. *  *  *  Assessing bleeding risk before surgery  How do you advise patients about to go into surgery who say they bruise easily? This situation comes up frequently. In the case of emergency/urgent surgery, there’s not time for a prolonged evaluation. Take a careful bleeding history: Always ask patients about any history of spontaneous bleeding. Ask about epistaxis, gingival bleeding, rectal bleeding, heavy menstrual periods. Go down the body from head to toe. It’s also important to ask about hemostatic challenges. Has the patient had any prior surgeries? If it’s a woman, has she had pregnancies and deliveries? Did the patient experience abnormal bleeding with those challenges? Prompt patients to consider whether they have had surgery that they might not think about, such as tooth extraction, tonsil removal, or polyps removed from their colon. Seek to establish the time course: Is this a patient who has had abnormal bleeding for their entire life, or did it start later in life? This can provide clues about whether this is a congenital bleeding disorder or an acquired condition. Ask about such comorbidities as liver and kidney disease, which can be associated with an increased bleeding risk. Get a complete medication list. Anticoagulants and antiplatelets are the obvious culprits but consider fish oil and selective serotonin reuptake inhibitors (SSRIs) for bleeding. Ask about family history: Is there a family member who has a diagnosed bleeding disorder or even a history of abnormal bleeding? Ask about social history: Are you engaged in any activities associated with an increased risk of trauma? Challenges to taking a bleeding history: Some bleeding symptoms are very common to the normal population. A surprisingly high percentage of people with no bleeding disorders report easy bruising, frequent nose bleeds as a child, heavy menstrual bleeding. Laboratory work-up What’s the basic lab evaluation? Complete blood count (CBC) Prothrombin time (PT) and partial thromboplastin time (PTT) Comprehensive metabolic panel to make sure the patient doesn’t have liver or kidney disease If the basic lab evaluation is normal can they have a bleeding disorder? Yes. The most common conditions are von Willebrand disease and platelet function disorder. Less common are rare disorders of fibrinolysis or blood vessel disorders that can lead to abnormal bleeding. Assessing patients with active bleeding (post catheterization) Consider whether bleeding is a complication of the procedure or a bleeding disorder. An efficient but thorough bleeding history is critical. Order a basic lab work-up and review medications looking for antiplatelet medications in particular. This approach is a very similar to a patient without active bleeding who is going into surgery. Direct oral anticoagulants (DOACs) and bleeding PT and PTT are insensitive to DOACs but order them anyway if the patient is bleeding. If the test is prolonged, that could suggest that there are substantial levels of drug in circulation. If the test results come back normal, that doesn’t rule out the possibility that there are clinically meaningful levels of drug circulation that are contributing to bleeding. Getting a rapid anti-Xa assay could provide more information, but many clinicians don’t have access to that test. If you can’t get the definitive lab test and the patient is having a serious bleed, err on the side of giving the reversal agent. *  *  *  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
Ever read through a study and wondered how to apply the hazard ratio, or if you should change your practice because of a secondary endpoint finding? In this episode, Lauren M. Catalano, MD, of the University of Pennsylvania, Philadelphia, explains all the common terms and why they matter in the context of the KEYNOTE-024 trial.  In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about how to prepare for an unexpected bad outcome. Practice points: Don’t skip over the statistical analysis portion of a paper. Use Google to find simple definitions for unfamiliar biostatistics terms. Understanding the statistical elements is essential to determining the quality of the research. * * * Understanding statistics in the context of KEYNOTE-024 Article discussed: Updated analysis of KEYNOTE-024: Pembrolizumab versus platinum-based chemotherapy for advanced non–small cell lung cancer with PD-L1 tumor proportion score of 50% or greater. J Clin Oncol. 2019 Mar 1;37(7):537-46.  Primary endpoint: The outcome that is necessary to ensure the efficacy of the trial. What is the study’s objective? The primary endpoint is defined prior to starting the study, which influences how many patients need to be enrolled to ensure statistical significance. This paper’s primary endpoint: Time since random assignment to disease progression or death. Secondary endpoint: These are interesting trends or observations that the investigators were able to determine, but for which the original study may not have been powered, meaning that they may not have enough data to determine the statistical significance. This paper’s secondary endpoints: Objective response rate (confirmed complete and partial responses) and safety. Hazard ratio: “Ratio” suggests that this is a comparison between the intervention and control arm. HR is a measure of an effect or intervention on the outcome of interest over a period of time (risk per unit of time). The outcome can be positive or negative. Confidence interval: Since it is not possible to survey the entire population, a confidence interval provides a range of values where the true value most likely falls. If the confidence interval crosses “1” then there is no difference between the arms of the study. Kaplan-Meier curve: Often used to illustrate survival. This is a graphical representation of hazard ratio, usually drawn as a step function. P value: The degree of error that we are willing to accept. Often P = .05, which means we are willing to accept a 5% risk that the hypothesis is incorrect. Crossover: Patients assigned in one arm of the study (usually the control arm) can be reassigned to the other arm (usually the intervention group). Intention to treat: A technique used in randomized, controlled trials in which patient outcomes are compared within the group the patient was originally assigned to. This may not reflect the treatment that the patient actually received. If the patient is in a group that is treated but then leaves that group, they are still counted in the original group. 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
A diagnosis of acute myeloid leukemia (AML) was once an emergency, requiring immediate treatment. Today, the need to start treatment is still urgent, but many patients can benefit by waiting a few days for testing to reveal a fuller picture of the disease. That’s the advice of James M. Foran, MD, of the Mayo Clinic. He joins Blood & Cancer host David H. Henry, MD, of the Pennsylvania Hospital, Philadelphia, to walk through some patient scenarios and the newest treatment options. In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about what patients do and do not remember from their visits. Practice points: Rapid testing results can drive important choices in the initial treatment of AML. Adjunctive therapies may improve survival by 7%-20% in appropriate patients. Although a total work-up may take up to 2 weeks, new research suggests it is feasible to get rapid sequencing/cytogenetic testing and assign treatment within 7 days. Treatment varies: Daunorubicin and cytarabine (Vyxeos) are still central treatment strategies, but there may be survival advantages (7%-20% improvement) by adding adjunctive therapies, if indicated. A few are listed below: Liposomal formulations of daunorubicin-cytarabine (CPX351) can have survival advantages in therapy-related AML or AML with myelodysplastic syndrome (MDS)-related changes. Gemtuzumab (Mylotarg) may be indicated for core binding factor (CBF) AML. Midostaurin (Rydapt) may improve survival in patients with FMS-like tyrosine kinase (FLT) 3 Enasidenib (Idhifa) may be indicated in patients with IDH mutations. Options for elderly patients: In a recent study, CC 486 (oral azacitidine) showed a significant survival advantage and remission duration in elderly patients with AML. The drug is not yet available but could eventually be a maintenance therapy option for patients who do not go on to transplant. Azacitidine, plus or minus an IDH2 inhibitor, showed much higher remission rates in elderly patients, but did not translate into a survival advantage. AML in the outpatient setting: Many patients with AML are being increasingly managed as outpatients, which ultimately will require a different kind of support infrastructure in our hospitals and clinics. Show notes by Debika Biswal Shinohara, MD, PhD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. Dr. Henry and Dr. Yurkiewicz reported having no financial conflicts relevant to this episode. Dr. Foran reported advisory board membership with Pfizer, Jazz Pharma, and Novartis.  * * *  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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