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Blood & Cancer

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The official podcast feed of MDedge Hematology-Oncology, part of the Medscape Professional Network. Our Tuesday show brings you the latest hem/onc news. On Thursdays, Dr. David Henry interviews key opinion leaders and rising stars in hematology and oncology. The information in this podcast is provided for informational and educational purposes only.
123 Episodes
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In this episode, we discuss updated guidelines on the screening and management of hepatitis B virus (HBV) in patients about to start anticancer therapy. The guidelines come from an American Society of Clinical Oncology Provisional Clinical Opinion (PCO) published earlier this year. Jessica P. Hwang, MD, of MD Anderson Cancer Center, and Andrew Artz, MD, of City of Hope, are cochairs of the ASCO PCO. They joined host David H. Henry, MD, to discuss the guidelines. Epidemiology of HBV Data suggest chronic HBV infection affects 257 million people globally. In the United States, chronic HBV infection has a prevalence of less than 1%, but the prevalence of past HBV can be 5%-40% in high-risk populations. High-risk populations include people born in endemic areas (i.e., Africa, Asia, and South America), those with injection drug use, men who have sex with men, and people with household contacts who have HBV. In patients with cancer, the prevalence of past HBV infection is 5%-10%, with a 0.5% prevalence of chronic HBV. HBV and oncology: Who should be screened? The ASCO PCO recommends universal HBV screening in all patients planning or undergoing anticancer therapy. To screen, practitioners should order three tests before initiating anticancer therapy: hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc) total immunoglobulin (Ig) or IgG, and hepatitis B surface antibody (anti-Hbs). Interpretation of serology Chronic infection: HBsAg (+), anti-HBc (+), anti-HBs (-). Resolved past infection: HbsAg (-), anti-HBc (+), anti-HBs (+). Past infection, isolated core: HbsAg (-), anti-HBc (+), anti-HBs (-). Vaccine-induced immunity: HbsAg (-), anti-HBc (-), anti-HBs (+). Recommended treatment and/or monitoring Once a patient is infected, the HBV incorporates into the host genome and can live latently, so the patient is at risk of reactivation with immunosuppressive anticancer therapy (with chronic or past infection). Certain therapies pose a heightened risk of HBV reactivation, including anti-CD20 monoclonal antibodies and stem cell transplant. Patients receiving checkpoint blockade immunotherapy should be monitored closely for reactivation, though autoimmune hepatitis and high-dose steroids used in treating immune-related events could confound the reactivation of HBV. Further guidelines specific to checkpoint blockade immunotherapy are dichotomized and can be found in the ASCO PCO. In patients with chronic HBV infection receiving any systemic anticancer therapy, the ASCO PCO recommends antiviral prophylactic therapy during anticancer therapy and for a minimum of 12 months after anticancer therapy, with consultation of an HBV specialist. Entecavir, tenofovir disoproxil fumarate, and tenofovir alafenamide are well tolerated and have a low rate of viral resistance, making them favorable for patients who need to be treated. Implementing a screening program Recommend a multidisciplinary team approach, including physicians, pharmacists, and public health professionals. Utilize EHRs to incorporate alerts for screening and embedding screening into order sets. Ensure that positive test results are delivered to the appropriate medical team. Link patients into care for treatment and/or monitoring. Source and resources The ASCO PCO was published in the Journal of Clinical Oncology: https://bit.ly/3pClNPo. Additional resources are available on the ASCO website: https://bit.ly/35E0nt0. An infographic is also available: https://bit.ly/3pBuE3K. Show notes written by Sheila DeYoung, DO, a resident at Pennsylvania Hospital, Philadelphia. Disclosures Dr. Hwang disclosed relationships with Gilead Sciences, Merck Sharp & Dohme, and the Asian Health Foundation. Dr. Artz disclosed research funding from Miltenyi Biotec. Dr. Henry has 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
How to kill a trial

How to kill a trial

2020-11-1707:10

The Tomosynthesis Mammography Imaging Screening Trial (TMIST) was designed to see if 3-D mammography, or tomosynthesis, could help personalize screening and if 3-D is actually better than the less expensive 2-D mammography. TMIST is the largest breast cancer screening trial in the United States, with a cost of $100 million and a planned enrollment of 165,000 women. There's just one problem. The study is falling short on enrollment of patients and participating sites. Will this mean the death of TMIST? For more details, see coverage of TMIST on Medscape: NCI May 'Kill' Major Mammography Trial, Says Advisor https://www.medscape.com/viewarticle/937918 Email Blood & Cancer at podcasts@mdedge.com.
Can receiving all posttransplant care at home benefit patients undergoing hematopoietic stem cell transplant (HSCT)? Researchers are conducting phase 2 trials to find out. Anthony D. Sung, MD, of Duke University School of Medicine, described this research to host David H. Henry, MD. Dr. Sung outlined the process of receiving post-HSCT care at home and discussed Duke's clinical trials assessing the impact of home care on costs, quality of life, the microbiome, and graft-versus-host disease (GVHD). Dr. Sung also discussed another Duke trial investigating whether a probiotic can prevent COVID-19. Post-HSCT care at home: How it works Cell collection (if applicable), conditioning, and HSCT all take place in the outpatient setting. From day 1 after transplant onward, the patient receives all care at home. A nurse practitioner or physician assistant visits the patient every morning to draw labs, which are run at the hospital. A nurse visits every afternoon to give the patient supportive care. Patients are given the tools to video chat with physicians. Patients must live within 1 hour of Duke’s transplant center or relocate to furnished apartments near the transplant center. Phase 1 trial: Feasible and safe Dr. Sung and colleagues have completed a phase 1 trial, which suggested that post-HSCT care at home was feasible and safe. Outcomes were similar to outcomes in patients who do not receive post-HSCT care at home. The results were presented at ASH 2017 (Blood. 2017;130:745; https://bit.ly/2UelgVo). Phase 2 trials: Microbiome, GVHD, and other outcomes With one phase 2 trial (NCT01725022), Dr. Sung and colleagues aim to determine if: Patients can maintain their normal bowel microbiota by receiving post-HSCT care at home, as opposed to outpatient or inpatient care. Treatment-related morbidities and mortality are similar between the groups. Care at home improves quality of life and reduces costs. Trial details can be found here: https://bit.ly/2JRnY0Y. In the other phase 2 trial (NCT02218151), the main goal is to compare the incidence of grade 2-4 acute GVHD at 6 months in patients receiving care at home vs. inpatient or outpatient care. The theory is that maintaining the microbiome will reduce the risk of GVHD. A case of GVHD can add $100,000 to the cost of care, Dr. Sung noted. Trial details can be found here: https://bit.ly/32vr8y3. COVID-19 and the microbiome Dr. Sung and colleagues are also conducting a trial of Lactobacillus rhamnosus GG (LGG) as prophylaxis for COVID-19 (NCT04399252). Research has shown that giving LGG to mice with Pseudomonas aeruginosa pneumonia can: Help prevent lung injury and significantly improve survival (Shock. 2013;40[6]:496-503; https://bit.ly/3khQBRr). Help modulate the microbiome and immune system, leading to decreased inflammation, TNF-alpha, IL-2, and IL-6, as well as increased regulatory T cells (Clin Nutr. 2017;36[6]:1549-1557; https://bit.ly/35lENJZ). Dr. Sung noted that TNF-alpha, IL-2, and IL-6 have also been implicated in COVID-19 and associated with increased lung injury. Dr. Sung and colleagues have theorized that LGG could decrease lung injury and the symptoms of COVID-19 and perhaps even prevent COVID-19. The researchers are conducting a randomized trial of LGG in household contacts of patients with COVID-19 (https://bit.ly/2GRSC9x). For more details on the trial, email protect-ehc@duke.edu or visit https://bit.ly/2IsLjWh. Disclosures: Dr. Sung and Dr. Henry have no relevant disclosures. Duke's transplant trials are funded by grants from the National Institutes of Health. Funding for the COVID-19 trial is provided by the Duke Microbiome Center and philanthropic giving. The LGG and placebo used in the trial are provided by DSM. * * * For more MDedge podcasts, visit mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd
Hematology Oncology News:  IMRT new standard of care for high-risk cervical cancer: https://bit.ly/3k7ji3y Real-world results with checkpoint inhibitors found inferior to trial results: https://bit.ly/35cIt0v Are HMAS appropriate for posttransplant maintenance in acute leukemias?: https://bit.ly/3lfqsE7 You can email the show at podcasts@mdedge.com.
In this episode, we review how PD-L1 inhibitors and COVID-19 have changed the management of non-small cell lung cancer (NSCLC). Jeffrey Crawford, MD, and Susan Blackwell, PA, both of Duke Cancer Institute, join host David H. Henry, MD, to discuss the use of pembrolizumab in NSCLC, two studies of PD-L1 inhibitors presented at ESMO 2020, and how COVID-19 has affected NSCLC care, particularly the use of granulocyte colony-stimulating factor (G-CSF). Diagnosis and treatment of NSCLC What information should be obtained from a biopsy? Is this lung cancer? If so, what kind of lung cancer is it: Small-cell lung cancer or NSCLC? Which subtype? Molecular studies for targets, including ALK, KRAS, EGFR, PD-L1. Treatment with pembrolizumab: If, for example, a patient has NSCLC and is positive for PD-L1, the treatment of choice is pembrolizumab. A multidisciplinary approach is essential to provide comprehensive education and care to patients taking pembrolizumab (and other immunotherapies). Pembrolizumab can have many side effects, including itching, fatigue, thyroiditis progressing to hypothyroidism, hypophysitis, or another off-target “-itis.” Ms. Blackwell and Dr. Crawford recommend listening to patients, checking the thyroid routinely, and checking cortisol based on index of suspicion. NSCLC studies presented at ESMO 2020 KEYNOTE-024 5-year OS update: First-line (1L) pembrolizumab (pembro) vs platinum-based chemotherapy (chemo) in patients (pts) with metastatic NSCLC and PD-L1 tumour proportion score (TPS) ≥50%. The 5-year survival is greater than 30% with pembrolizumab in this study. Historically, 5-year survival has been 1% to 2% in patients treated with chemotherapy alone, Dr. Crawford said. In the control arm of this study, patients received chemotherapy and then crossed over into the pembrolizumab arm, so overall survival was 16% at the 5-year mark. The results suggest immunotherapy should be used first-line if patients meet criteria, Dr. Crawford said. Source: Abstract LBA51. https://bit.ly/3mMYLTK. EMPOWER-Lung 1: Phase III first-line (1L) cemiplimab monotherapy vs platinum-doublet chemotherapy (chemo) in advanced non-small cell lung cancer (NSCLC) with programmed cell death-ligand 1 (PD-L1) ≥50%.  The PD-L1 inhibitor cemiplimab improved overall and progression-free survival in NSCLC patients when compared with chemotherapy alone. Abstract LBA52. https://bit.ly/3mLT6xb. The effects of COVID-19 on NSCLC care Logistically, it’s more difficult to see patients during the pandemic, Dr. Crawford noted, but the many potential side effects of immunotherapy make it necessary to see patients regularly in person. How has COVID-19 affected the concern of febrile neutropenia and the use of G-CSF? Dr. Crawford said the pandemic has heightened the concern about infection risk. Prior guidelines for G-CSF: Before the pandemic, guidelines suggested routine prophylactic G-CSF in patients with a greater than 20% risk of febrile neutropenia. In patients with 10% to 20% risk, the recommendation was to consider the use of G-CSF based on the patient population and risk factors. Pandemic-specific guidelines for G-CSF: The National Comprehensive Cancer Network (NCCN) recommended relaxing guidelines during the pandemic. If the risk is greater than 20%, NCCN still recommends giving G-CSF. If the risk is 10% to 20%, NCCN recommends giving G-CSF even in the absence of additional risk factors. Dr. Crawford noted that lung cancer patients receiving chemotherapy are typically in the 10% to 20% risk category. Download the COVID-specific NCCN guidelines: https://bit.ly/3jQIco5. G-CSF biosimilars The most common complaint with biosimilars is bone pain. Ms. Blackwell advises first treating bone pain with acetaminophen or ibuprofen and warm blankets. For refractory pain, she suggests a low-dose narcotic or dexamethasone. Consider an antihistamine for prophylaxis, as patients report this can help with symptoms. Show notes written by Ronak Mistry, DO, a resident at Pennsylvania Hospital, Philadelphia. Disclosures: Dr. Crawford is on advisory boards at Amgen and Merck, makers of Onpro/Neulasta (pegfilgrastim) and Keytruda (pembrolizumab). Ms. Blackwell and Dr. Henry have no 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
News from MDedge Hematology-Oncology: New estimates for breast cancer risk with HRT: https://bit.ly/37VT0Pt BMJ study: https://bit.ly/2TKDIVt Lancet meta-analysis: https://bit.ly/3kUdbRl Single and multifraction SBRT found comparable for lung metastases: https://bit.ly/2HS36pR Statins may lower risk of colorectal cancer: https://bit.ly/3kLbR37 Email Blood & Cancer at podcasts@mdedge.com.  Follow us on Twitter @MDedgeHemOnc.
In this episode, we review the latest guidelines on antiemetics from the American Society of Clinical Oncology (ASCO). Host David H. Henry, MD, is joined by ASCO guideline author Paul J. Hesketh, MD, of Lahey Hospital and Medical Center in Burlington, Mass. Dr. Hesketh explains the recommendations for antiemetic use in cancer patients receiving checkpoint inhibitors (CPIs) or high-, moderate-, or low-emetic-risk antineoplastic agents. Checkpoint inhibitors The update to ASCO’s guidelines was primarily driven by questions about antiemetic use in patients receiving CPIs, according to Dr. Hesketh. After a literature review, Dr. Hesketh and coauthors concluded that: Patients receiving CPIs alone do not require an antiemetic regimen. When CPIs are given with chemotherapy, there is no need to modify the antiemetic regimen. Dexamethasone does not compromise the efficacy of CPIs. High-emetic-risk antineoplastic agents Adults treated with cisplatin and other high-emetic-risk single agents should be offered a four-drug combination: an NK1 receptor antagonist, a serotonin (5-HT3) receptor antagonist, dexamethasone, and olanzapine on day 1. Dexamethasone and olanzapine should be continued on days 2-4, as cisplatin can cause delayed emesis. Adults treated with an anthracycline plus cyclophosphamide should be offered a four-drug combination: an NK1 receptor antagonist, a 5-HT3 receptor antagonist, dexamethasone, and olanzapine on day 1. Unlike with cisplatin, only olanzapine should be continued on days 2-4. Olanzapine is an effective antiemetic in a number of settings, Dr. Hesketh said. For example, olanzapine is useful in the setting of hematopoietic stem cell transplant. A 5-mg dose of olanzapine has proven effective and may be better tolerated than a 10-mg dose. Moderate-emetic-risk antineoplastic agents Adults treated with higher-dose carboplatin (area under the curve ≥4 mg/mL per min) should be offered a three-drug combination: an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone on day 1. Adults treated with moderate-emetic-risk antineoplastic agents (excluding higher-dose carboplatin) should be offered a two-drug combination: a 5-HT3 receptor antagonist and dexamethasone on day 1. Adults treated with cyclophosphamide, doxorubicin, oxaliplatin, and other moderate-emetic-risk antineoplastic agents known to cause delayed nausea and vomiting may be offered dexamethasone on days 2-3. Low-emetic-risk antineoplastic agents Adults treated with low-emetic-risk antineoplastic agents (e.g., fluorouracil, gemcitabine) should be offered a single dose of a 5-HT3 receptor antagonist or a single 8-mg dose of dexamethasone before antineoplastic treatment. Cannabinoids There is no good data on the use of cannabinoids, apart from those cannabinoids approved by the Food and Drug Administration, according to Dr. Hesketh. The ASCO guidelines state: There is insufficient evidence to make a recommendation regarding medical marijuana to prevent nausea and vomiting in cancer patients receiving chemotherapy or radiation. Similarly, there is insufficient evidence to make a recommendation on the use of medical marijuana in place of the approved cannabinoids dronabinol and nabilone for the treatment of nausea and vomiting in cancer patients receiving chemotherapy or radiation. SOURCE: Hesketh PJ et al. J Clin Oncol. 2020 Aug 20;38(24):2782-97. https://bit.ly/3oxahUP Show notes written by Alesha Levenson, MD, a resident at Pennsylvania Hospital, Philadelphia. Disclosures: Dr. Hesketh disclosed institutional research funding from AstraZeneca and F. Hoffmann-La Roche. Dr. Henry has no relevant disclosures. * * * For information on the negative effects of marijuana, listen to our sister podcast, Psychcast, on MDedge (https://bit.ly/3mBM6TB), Spotify (https://spoti.fi/3mwVvvn), or wherever you get your podcasts. * * * 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.
Hematology-Oncology News:  National lung cancer screening guidelines may miss younger African American individuals at high risk: https://bit.ly/3e2CmhV  Standard treatment lacking in relapsed / refractory AML: https://bit.ly/3kzoUVh (03:08) Patients can read your clinical notes starting Nov. 2: https://bit.ly/3mnuudL (05:40) Update: The deadline for "open notes" has been extended to April 5, 2021. You can email the show at podcasts@mdedge.com.  
In this episode, we review three hematology cases. One case illustrates the work-up and treatment of immune thrombocytopenia (ITP). Another case demonstrates how to diagnose and manage heparin-induced thrombocytopenia (HIT). And the final case is a patient who presented with anemia, a new mitral valve murmur, and mild splenomegaly. Host David H. Henry, MD, reviews these cases with three residents from Pennsylvania Hospital in Philadelphia – Sheila De Young, DO; Ronak Mistry, DO; and Debika Shinohara, MD, PhD. Case 1: Suspected ITP with Sheila De Young, DO Patient presentation: A 50-year-old female with no past medical history and incidental platelet count of 4,000/microL (normal 150,000-450,000/microL [150-450 x 109/L]). On physical exam, there was no lymphadenopathy, and the spleen was nonpalpable. She had obvious petechiae on her legs. A urine pregnancy test was negative. Her hemoglobin and white blood cell counts were normal via complete blood count. ITP definition: Acquired thrombocytopenia caused by autoantibodies against platelet antigens. One of the most common causes of thrombocytopenia in otherwise asymptomatic adults. To consider: Increased destruction, decreased production, and pseudothrombocytopenia To ensure the platelet count is not falsely low (in the case of pseudothrombocytopenia), looking at a peripheral smear is helpful. If red blood cells and white blood cells appear normal, we can exclude pseudothrombocytopenia. Work-up: We need to rule out secondary causes of thrombocytopenia such as HIV, hepatitis C, chronic lymphocytic leukemia, systemic lupus erythematosus, etc. Management/treatment: In the acute setting, the treatment for ITP is intravenous immunoglobulin and steroids. Long-term management of ITP includes steroids, splenectomy, thrombopoietin receptor agonists (romiplostim/eltrombopag), and rituximab. Case conclusion: This patient was found to have ITP. Shared decision-making led to the patient receiving a thrombopoietin receptor. Case 2: Possible HIT with Ronak Mistry, DO Patient presentation:  A male with ischemic leg and creatinine phosphokinase greater than 4,000 units/L. His platelet count was 101,000/microL on admission, 70,000/microL on the second day, and 60,000/microL on the third day. The patient was on prophylactic subcutaneous heparin for 48 hours, so the surgery team considered HIT to explain the drop in platelets. HIT definition: A life-threatening complication of exposure to heparin. Results from autoantibody directed against endogenous platelet factor 4 (PF4) in complex with heparin. To consider: Determine baseline platelet count, what type of heparin the patient received, and look at when the heparin was administered in relation to when the platelet count dropped. HIT is far less common in patients who receive subcutaneous heparin versus intravenous heparin. Typically, we see a 50% decrease in platelet count 5-10 days following exposure to heparin. Work-up: In the inpatient setting, it is important to consider other causes that predispose patients to thrombocytopenia (i.e., critical illness, medications). Thrombocytopenia can represent a consumptive process of platelets secondary to tissue injury in the setting of elevated creatine phosphokinase. Diagnosis: Enzyme-linked immunosorbent assays (ELISAs) can detect the presence of PF4-heparin antibody. ELISA should be followed by a confirmatory test. The serotonin release assay is preferred among diagnostic tests for HIT. Management/treatment: Stop heparin immediately. Giving more platelets is not the solution. It increases a person’s risk for thrombotic events. The patient needs to be placed on different anticoagulation, such as argatroban or fondaparinux, to carry them through this procoagulant time frame. Case conclusion: HIT was ruled out in this patient. Case 3: Anemia case with Debika Shinohara, MD, PhD Patient presentation: A female, age 45 years, with a 4-month history of intermittent fevers and unintentional weight loss. Her hemoglobin was 8 g/dL, but she had otherwise unremarkable blood work. On physical exam, she was found to have a new mitral valve murmur and mild splenomegaly. To consider: Increased destruction versus decreased production of red blood cells. Low reticulocyte count (<5%) suggests decreased production. Work-up: Test vitamin B12, folate, and iron (ferritin, transferrin saturation, and total iron-binding capacity). Elevated transferrin is characteristic of anemia of chronic disease/inflammation. Peripheral smear: The red blood cells are normocytic and normochromic in most cases of anemia of inflammation. In the setting of elevated transferrin, new-onset murmur, and fever of unknown etiology, it is important to do infectious work-up with blood cultures and cardiac ECG to rule out infective endocarditis. Infective endocarditis: Systemic manifestations include Janeway lesions, Roth spots, and Osler nodes. Infection with Streptococcus bovis indicates a need for workup of colon cancer. Case conclusion: Blood cultures came back positive for viridans streptococci. The patient was found to have a left atrial myxoma, which was likely the nidus of infection that had seeded the bloodstream. The patient was started on intravenous antibiotics and seen by cardiothoracic surgery to remove the myxoma. Show notes written by Alesha Levenson, MD, a resident at Pennsylvania Hospital. Disclosures: All participants in this episode have no relevant financial 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
Hematology Oncology News: Study advances personalized treatment for older breast cancer patients (https://bit.ly/3dHieSk) Delayed cancer screening could cause increase in deaths, study says (https://bit.ly/34afIAS) Blood group O linked to decreased risk of SARS-CoV-2 infection (https://bit.ly/2T8qilF) Email Blood & Cancer at podcasts@mdedge.com or follow us on Twitter @MDedgeHemOnc.  
How do patients with thoracic cancers fare when they develop COVID-19? The researchers behind the TERAVOLT registry are trying to find out. TERAVOLT investigator Alessio Cortellini, MD, of the University of L’Aquila (Italy), joined host David Henry, MD, to discuss the TERAVOLT registry and its findings, which were recently presented at the European Society for Medical Oncology Virtual Congress 2020. What is TERAVOLT? TERAVOLT is an international registry of patients with thoracic cancers and COVID-19 that was launched in March 2020 by Marina Garassino, MD, of the National Cancer Institute of Milan. The registry enrolls patients with any solid thoracic cancer – small cell and non–small cell lung cancer, mesothelioma, thymic epithelial tumors, and other pulmonary neuroendocrine neoplasms. Patients are deemed to have COVID-19 if they test positive by reverse transcription–polymerase chain reaction or serology or if they have radiologic or clinical characteristics of COVID-19 and known interaction with a COVID-positive person. TERAVOLT website: http://teravolt-consortium.org/ TERAVOLT data at ESMO 2020 Data presented at ESMO 2020 included 1,012 patients from 20 countries, mostly in Europe (74%) and North America (23%). The data encompass patient characteristics, oncologic treatment and COVID-directed therapy, and outcomes. In all, 32% of patients died of COVID-19. A multivariable model revealed several factors associated with an increased risk of mortality, including: Eastern Cooperative Oncology Group (ECOG) performance status of 2 or greater (odds ratio, 3.6; P < .001) Stage IV cancer (OR, 1.9; P < .001) Former or current smoker (OR, 1.8; P < .01) Prior steroid use (OR, 1.7; P < .01) Age 65 years or older (OR, 1.5; P = .01) Receiving chemotherapy or no systemic treatment versus immunotherapy, chemoimmunotherapy, or targeted therapy (OR, 1.4; P = .03) Espinar JB et al. ESMO 2020, Abstract LBA75. https://bit.ly/371aGIJ A tool to predict mortality Based on their findings, TERAVOLT researchers developed a nomogram that can help predict mortality in patients with thoracic cancers and COVID-19. Patients receive points based on ECOG performance status, cancer stage, smoking habits, age, steroid use, and systemic cancer treatment. For example, a 70-year-old smoker with an ECOG score of 2 who is receiving third-line treatment with docetaxel for stage IV squamous non–small cell lung cancer would have a score of 260 points, which translates to a greater than 60% risk of death. A 50-year-old never-smoker with an ECOG score of 0 who is receiving first-line osimertinib for stage IV non–small cell lung cancer would have a score of 55 points, which translates to a less than 20% risk of death. Disclosures: Dr. Cortellini and Dr. Henry have 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  
Hematology-Oncology News:  Radiotherapy planning scans reveal breast cancer patients’ CVD risk (https://bit.ly/2FeoJiH) FDA OKs combination immunotherapy for first-line mesothelioma treatment (https://bit.ly/2Ff77mS) Apatinib plus gefitinib: Better PFS but more toxicity (https://bit.ly/34IyVsn) Atezolizumab strikes out in ovarian cancer (https://bit.ly/3iPjXG1) Email Blood & Cancer at podcasts@mdedge.com and learn more at https://www.mdedge.com/podcasts/blood-cancer        
Lorenzo Norris, MD, host of Psychcast, joins Blood & Cancer host David Henry, MD, to discuss steps clinicians can take to alleviate the distress associated with receiving a diagnosis of cancer. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. Dr. Henry is clinical professor of medicine at the University of Pennsylvania, Philadelphia. Both doctors have no disclosures. A full transcript of this episode is available here: A conversation on mental health and cancer https://bit.ly/2Fgat9k   Take-home points Cancer patients have always been susceptible to developing depression and anxiety after receiving their distressing diagnoses. During the COVID-19 pandemic, the risk for depression and anxiety are even greater because patients face separation from their oncology treatment teams and for some, delays in treatment. Major depressive disorder (MDD) occurs in up to one-third of cancer patients, and any depressive disorder can be seen in about half. Another concern is how to screen for depression in the context of cancer. Dr. Norris suggests using the Patient Health Questionnaire–2 (PHQ-2) screener, or the question: “Are you sad or depressed?” Answering those questions can give patients the opportunity to open up about their emotions. Signs of depression in cancer include nonadherence to treatment, changes in mood and anxiety affecting daily functioning at home or work, and demoralization, which is defined as helplessness, isolation, and despair in the face of overwhelming stressors. Summary An emotional upset, such as disbelief, despair, or even denial, might occur immediately after receiving a cancer diagnosis. A depressive disorder, however, is a persistently depressed, sad mood with changes in functioning that affect the patient, his/her family, and even engagement with treatment. Findings of studies about the prevalence of depression in patients with cancer vary depending on the type of screening and/or diagnostic tool used. In general, the prevalence of MDD is up to 38%, and the prevalence of any depressive disorder is up to 58%. The prevalence of depression is even greater in patients with advanced cancer. In the general population, the 12-month prevalence of MDD is 6%, and the lifetime prevalence is 16%. It’s useful to think about stress along a continuum of diagnoses ranging from a normal expected stress syndrome, an adjustment disorder, MDD triggered by the event, depression secondary to a general medical condition as can occur in central nervous system and pancreatic cancer, or even a substance-induced mood disorder from either prescribed medications or perhaps a form of coping that has turned maladaptive. Cognitive-behavioral therapy (CBT) can be explained as examining the way thoughts influence emotions and behavior. When using CBT with cancer patients, a good place to start is checking in on their understanding of their diagnosis, their prognosis, and current and future treatments. The goal is to see whether they have unnecessary cognitive distortions that may be affecting their emotions and behaviors. During periods of extreme stress, CBT can help patients by emphasizing the use of adaptive thoughts, and identifying maladaptive thoughts and behaviors as opportunities for intervention. To screen for depression, it may be enough to ask: “Are you depressed?” As a screening tool, the PHQ-2 asks only two questions: “Over the last 2 weeks, how often have you been bothered by the following problems: Little interest or pleasure in doing things, or been feeling down, depressed or hopeless? The PHQ-2 score ranges from 1 to 6, and even at the lowest score, it has a sensitivity and specificity of 90.6% and 65.4%, respectively, in detecting any depressive disorder. References Krebber AMH et al. Psycho-oncology. 2014 Feb;23(2)121-30. Walker J et al. Ann Oncol. 2013 Apr 1;24(4):895-900. Trinidad AC et al. Psychiatr Ann. 2011;4(9):439-42. Daniels S. J Adv Pract Oncol. 2015 Jan-Feb;6(1):54-6. Other resources PHQ-2: https://www.hiv.uw.edu/page/mental-health-screening/phq-2 National Cancer Institute: Depression–Health Professional Version: https://www.cancer.gov/about-cancer/coping/feelings/depression-hp-pdq
Hematology-Oncology News:  Divergent findings with paclitaxel and nab-paclitaxel in TNBC (https://bit.ly/33vemjS) Palbociclib plus letrozole improves PFS in advanced endometrial cancer (https://bit.ly/2GIUl08) Global stomach cancer deaths decline as colorectal cancer deaths stagnate, rise (https://bit.ly/33zBVs1) You can email the show at podcasts@mdedge.com and you can learn more about the show at https://www.mdedge.com/podcasts/blood-cancer    
There were a number of practice-changing and ground-breaking studies presented at the ESMO 2020 Virtual Congress, according to our guest in this episode. Alan P. Lyss, MD, subprincipal investigator for Heartland Cancer Research NCORP, joined host David H. Henry, MD, to review highlights from ESMO 2020. The pair discussed studies on gynecologic, breast, lung, gastrointestinal, and genitourinary cancers, as well as studies of anemia and COVID-19 in cancer patients. COVID-19 and cancer LBA77: Anti-SARS-CoV-2 antibody response in patients with cancer and oncology healthcare workers: A multicenter, prospective study. https://bit.ly/3cNNkar This study suggests SARS-CoV-2-specific IgG antibody response is not different between cancer patients (n = 61) and subjects without cancer (n = 105). Overall, 83.8% of subjects were IgG-positive, and there was no significant difference in IgG positivity between the cancer patients and the health care workers (P = .39). LBA83: Outcomes of the 2019 novel coronavirus in patients with or without a history of cancer: A multi-centre North London experience. https://bit.ly/2EJMpv4 This study suggests COVID-19 patients with a history of cancer may have a similar risk of death as COVID patients without a history of cancer, with exceptions. The odds ratio for mortality, comparing the cancer patients (n = 30) to the non-cancer patients (n = 90), was 1.05. The odds ratio for mortality was 4.05 for cancer patients who had received systemic therapy in the prior 28 days. Lung cancer: Radiotherapy LBA3_PR: An international randomized trial, comparing post-operative conformal radiotherapy (PORT) to no PORT, in patients with completely resected non-small cell lung cancer (NSCLC) and mediastinal N2 involvement: Primary end-point analysis of LungART (IFCT-0503, UK NCRI, SAKK) NCT00410683. https://bit.ly/3jtojUo This study enrolled 501 patients with completely resected NSCLC and mediastinal N2 involvement, and they were randomized to PORT or no PORT. There was no significant between-arm difference in disease-free survival (DFS) or overall survival (OS). The 3-year DFS rate was 47.1% with PORT and 43.8% with no PORT. The 3-year OS rate was 66.5% and 68.5%, respectively. These results suggest conformal PORT should not be standard care in all completely resected N2 NSCLC patients, according to Dr. Lyss. “This may have been the most obviously and immediately practice-changing study among those I heard presented,” he said. Endometrial cancer LBA28: A randomised double-blind placebo-controlled phase II trial of palbociclib combined with letrozole (L) in patients (pts) with oestrogen receptor-positive (ER+) advanced/recurrent endometrial cancer (EC): NSGO-PALEO / ENGOT-EN3 trial. https://bit.ly/2SanTX1 This study enrolled 77 patients with ER+ advanced or recurrent endometrial cancer, and they were randomized to palbociclib plus letrozole or placebo plus letrozole. The median progression-free survival (PFS) was 8.3 months in the palbociclib arm and 3 months in the control arm. Dr. Lyss called this a “small” but “important” study. He and Dr. Henry agreed that a confirmatory study is needed. Breast cancer LBA5_PR: Abemaciclib in high risk early breast cancer. https://bit.ly/3igxbvw This trial enrolled 5,637 women with hormone receptor-positive, HER2/neu oncogene-negative, early breast cancer. They were randomized to receive standard endocrine therapy (ET) alone or standard ET with abemaciclib. The 2-year invasive DFS rate was 92.2% with abemaciclib and 88.7% with ET alone (hazard ratio, 0.747; P = .0096). Dr. Lyss said these data suggest abemaciclib could have “the potential to save many thousands of lives.” However, he noted that 16% of patients discontinued abemaciclib prematurely due to adverse events, and more than 300 of the 463 patients who stopped abemaciclib also stopped ET – a “disaster,” according to Dr. Lyss. LBA12: PALLAS: A randomized phase III trial of adjuvant palbociclib with endocrine therapy versus endocrine therapy alone for HR+/HER2- early breast cancer. https://bit.ly/2GbuluE This trial enrolled 5,760 patients with hormone receptor-positive/HER2-negative early stage breast cancer. They were randomized to palbociclib plus ET or ET alone. Results from this trial run counter to results from the abemaciclib trial, in that adding palbociclib to ET did not improve invasive DFS. The 3-year invasive DFS rate was 88.2% in the palbociclib arm and 88.5% in the ET-alone arm (HR, 0.93). Dr. Lyss said he can see no explanation for the different results with abemaciclib and palbociclib, but longer follow-up and analyses of biospecimens may shed some light. LBA17: ASCENT: A randomized phase III study of sacituzumab govitecan (SG) vs treatment of physician’s choice (TPC) in patients (pts) with previously treated metastatic triple-negative breast cancer (mTNBC). https://bit.ly/3ilHwGd The study enrolled 529 patients with relapsed/refractory metastatic TNBC. They were randomized to SG or single-agent physician’s choice of therapy (capecitabine, eribulin, vinorelbine, or gemcitabine). SG outperformed physician's choice. The median PFS was 5.6 months with SG and 1.7 months with physician’s choice. The median OS was 12.1 months and 6.7 months, respectively. LBA16: IMpassion130: Final OS analysis from the pivotal phase III study of atezolizumab + nab-paclitaxel vs placebo + nab-paclitaxel in previously untreated locally advanced or metastatic triple-negative breast cancer. https://bit.ly/33fYYb7 This trial enrolled 902 patients with locally advanced or metastatic TNBC. They were randomized to first-line nab-paclitaxel plus placebo or nab-paclitaxel plus atezolizumab. The median OS was 21 months in the atezolizumab arm and 18.7 months in the control arm (HR, 0.87, P = .0770). The 3-year OS in PD-L1-positive patients was 36% and 22%, respectively. “I think anybody would choose the combination with atezolizumab with a difference like that,” Dr. Lyss said. LBA15: Primary results from IMpassion131, a double-blind placebo-controlled randomised phase III trial of first-line paclitaxel (PAC) ± atezolizumab (atezo) for unresectable locally advanced/metastatic triple-negative breast cancer (mTNBC). https://bit.ly/36iEoIS This trial enrolled 651 patients with locally advanced or metastatic TNBC. They were randomized to first-line paclitaxel plus placebo or paclitaxel plus atezolizumab. Dr. Lyss noted that, unlike IMpassion130, the results of IMpassion131 were “completely negative.” In the PD-L1-positive population, the median PFS was 5.7 months in the placebo arm and 6.0 months in the atezolizumab arm (HR, 0.82; P = .20). In the overall population, the median PFS was 5.6 months and 5.7 months, respectively (HR, 0.86). It’s unclear why results from IMpassion130 and IMpassion131 differ, Dr. Henry noted. Steroid use, study design, or chance might all play a role, according to a discussant at ESMO.   Urothelial cancer LBA24: TROPHY-U-01 cohort 1 final results: A phase II study of sacituzumab govitecan (SG) in metastatic urothelial cancer (mUC) that has progressed after platinum (PLT) and checkpoint inhibitors (CPI). https://bit.ly/3kYvq7R This study enrolled 113 patients with unresectable locally advanced or metastatic urothelial cancer. All patients received SG. The overall response rate was 27% in the overall population and 25% in patients with liver metastasis. The median PFS was 5.4 months, and the median OS was 10.5 months. Dr. Henry said the response and survival data were “rather impressive,” and Dr. Lyss noted that biomarker studies might allow for better selection of patients who should receive SG. Gastrointestinal cancer LBA6_PR: Nivolumab (nivo) plus chemotherapy (chemo) versus chemo as first-line (1L) treatment for advanced gastric cancer/gastroesophageal junction cancer (GC/GEJC)/esophageal adenocarcinoma (EAC): First results of the CheckMate 649 study. https://bit.ly/2GcOroj This study enrolled 1,581 patients with GC, GEJC, or EAC, and 60% of patients were PD-L1-positive with a combined positive score (CPS) of at least 5. Patients were randomized to first-line treatment with nivolumab plus chemotherapy or chemotherapy alone (XELOX or FOLFOX). In patients with PD-L1 CPS ≥ 5, the median OS was 14.4 months in the nivolumab arm and 11.1 months in the chemotherapy arm (HR, 0.71; P < .0001). The median PFS was 7.7 months and 6.2 months, respectively (HR, 0.68; P < .0001). Dr. Lyss noted that using checkpoint inhibitors in the frontline or even adjuvant setting appears beneficial in this patient population, as demonstrated by additional trials presented at ESMO 2020: LBA7_PR (https://bit.ly/2GfXW65) LBA8_PR (https://bit.ly/3kYokQM) LBA9_PR (https://bit.ly/3ikBaaa).   Lung cancer: Checkpoint inhibitors Dr. Henry briefly discussed three abstracts on checkpoint inhibitors in NSCLC — LBA51, LBA52, and LBA53. LBA51: KEYNOTE-024 5-year OS update: First-line (1L) pembrolizumab (pembro) vs platinum-based chemotherapy (chemo) in patients (pts) with metastatic NSCLC and PD-L1 tumour proportion score (TPS) ≥50%. https://bit.ly/2ELdNsE The 5-year OS rate was 31.9% with pembrolizumab and 16.3% with chemotherapy (HR, 0.62). LBA52: EMPOWER-Lung 1: Phase III first-line (1L) cemiplimab monotherapy vs platinum-doublet chemotherapy (chemo) in advanced non-small cell lung cancer (NSCLC) with programmed cell death-ligand 1 (PD-L1) ≥50%. https://bit.ly/3jjSiy9 The median OS was 22.1 months in the cemiplimab arm and 14.3 months in the chemotherapy arm (P = .002). LBA53: Precision immuno-oncology for advanced non-small cell lung cancer (NSCLC) patients (pts) treated with PD1/L1 immune checkpoint inhibitors (ICIs): A first analysis of the PIONeeR study. https://bit.ly/2GbjhO0 This study revealed biomarkers that might help guide treatment with immune checkpoint inhibitors. Renal cell carcinoma 696O_PR: Nivolumab + cabozantinib vs sunitinib in first-line treatment for advanced renal cell carcinoma: First results from the randomized phase III CheckMate 9ER trial. https://bit.ly/30lEMmg This study enrolled 651 patients with previously untreated metastatic renal cancer. They were randomized to cabozantinib plus nivolumab or sunitinib. The median PFS was 16.6 months with the combination and 8.3 months with sunitinib. The median OS was improved with the combination as well (HR, 0.61). Dr. Lyss said these results support the use of nivolumab plus cabozantinib in this patient population. However, he also expressed reservations related to tolerability, quality of life, eligibility criteria, and short follow-up. Anemia 1822P: Impact of iron-deficiency management on quality of life in cancer patients: A prospective cohort study (CAMARA study). https://bit.ly/2Sf1TdE This study enrolled 248 patients with solid tumors, including 74.5% with absolute iron deficiency (transferrin saturation coefficient < 20%) and 191 with anemia. Patients were treated with intravenous iron, and their quality of life (FACT-An scores) improved significantly between study enrollment and each assessment. Dr. Henry said the take-home message is that clinicians shouldn’t miss anemia or iron deficiency, and they shouldn’t transfuse patients automatically but, instead, consider iron supplementation. Disclosures: Dr. Henry has no financial disclosures relevant to this episode. Dr. Lyss writes a column for MDedge Hematology/Oncology called Clinical Insights. 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
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How do patients fare when they have cancer and COVID-19? Researchers developed the COVID-19 and Cancer Consortium (CCC19) and the National Cancer Institute COVID-19 in Cancer Patients Study (NCCAPS) to gain some insight. In this episode, Brian Rini, MD, a professor of medicine at Vanderbilt University Medical Center, Nashville, Tenn., and host of The Uromigos podcast, explains what CCC19 and NCCAPS are. He also discusses findings from CCC19 that were presented at the European Society of Medical Oncology Virtual Congress 2020. NCCAPS (NCT04387656) NCCAPS is a natural history study of COVID-19 in patients with active cancer. It is a prospective study, funded by the National Cancer Institute, that is open at more than 500 centers. The study is open to U.S. adults who are receiving active cancer treatment and either have COVID-19 or are awaiting a SARS-CoV-2 test result. Researchers collect blood samples and other data from patients enrolled. Blood is collected at baseline and at regular intervals incorporated into patients’ normal oncology follow-up. The samples will be used to assess things like genomics, cytokine abnormalities, and coagulation parameters. No data from NCCAPS have been released to date, but more than 100 patients have been enrolled. For more information, visit the NCCAPS webpage: https://bit.ly/3ck8nBb. CCC19 (NCT04354701) CCC19 is a retrospective database that includes information on patients with active cancer or a history of cancer who have been diagnosed with COVID-19, with or without a confirmatory test. Health care providers or their proxies from the United States, European Union, Argentina, Canada, Mexico, and United Kingdom can report cases through the CCC19 website. All data are deidentified. More than 100 institutions are now part of CCC19. Data from CCC19 were presented in two abstracts at ESMO 2020: Wise-Draper TM et al. Abstract LBA71. https://bit.ly/3iUarm2 Grivas P et al. Abstract LBA72. https://bit.ly/33OKttP The data from LBA72, which includes nearly 4,000 patients, suggest cancer-specific factors are associated with a greater risk of 30-day all-cause mortality, including: Progressive cancer (adjusted odds ratio, 2.9). Hematologic malignancy (aOR, 1.7). Receiving cancer therapy within the past 3 months (aOR, 1.2). It still isn’t clear if certain cancer treatments increase the risk of mortality, Dr. Rini said, but researchers are investigating that. For more information on CCC19, visit https://ccc19.org/. Disclosures: Dr. Rini and Dr. Henry have no relevant 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
This week in Hematology and Oncology news: Large waistline linked to higher risk of prostate cancer death (https://bit.ly/3iRxmya) FOLFOXRI tops doublets as bevacizumab backbone for mCRC (https://bit.ly/32QpTKi) AI algorithm on par with radiologists as mammogram reader (https://bit.ly/35WnAXV) How I Treat: For low-risk MDS, treat 'what bugs patients most' (https://bit.ly/2ZU5TEU)   *  *  * Find more Blood & Cancer at https://www.mdedge.com/podcasts/blood-cancer Email the show at podcasts@mdedge.com
How has COVID-19 impacted medical students? Two students from Royal College of Surgeons in Ireland (RCSI), Dublin, describe their experiences in this episode. Evani Patel and Sarah Chen, both second-year medical students at RCSI, tell host David H. Henry, MD, how the COVID-19 pandemic has shaped their educational experience thus far. Now, the pandemic has shifted the students’ education to a mix of virtual and in-person learning at RCSI, but COVID-19 also impacted the pair’s summer studentships at University of Pennsylvania, Philadelphia. Typically, the studentships involve seeing patients, attending lectures, and completing projects. This year, however, the students were unable to travel to Philadelphia in person, so they completed their projects and attended lectures virtually. Disclosures: Ms. Chen, Ms. Patel, and Dr. Henry have 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
Hematology/Oncology News: Study supports multigene panel testing for all breast cancer patients with second primary cancers: https://bit.ly/3m6RyOGSource: https://bit.ly/2ZKXund Atezolizumab TNBC indication ‘in jeopardy’ because of phase 3 results: https://bit.ly/35rqzrl Alert: https://bit.ly/2Reh1HMTrial: https://bit.ly/2ZqqIqX Pralsetinib: Second drug for RET+ NSCLC approved in U.S.: https://bit.ly/3bTdGaz Unexpected results in new COVID-19 ‘cytokine storm’ data: https://bit.ly/3k8fIGL JAMA research letter: https://bit.ly/35ubxB4 You can email the show at podcasts@mdedge.com    
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