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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.
46 Episodes
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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

2019-08-1500:34:52

  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
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