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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.
64 Episodes
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Treatment tips in CLL

Treatment tips in CLL

2020-02-2000:23:11

The million-dollar question in the treatment of chronic lymphocytic leukemia (CLL) is what to do after a patient relapses following treatment with venetoclax. Anthony Mato, MD, and Lindsey Roeker, MD, both of Memorial Sloan Kettering in New York, join podcast host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to explore the evidence about this question and to review the initial patient work-up and treatment strategies. In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, discusses patients compliance and how clinician biases can influence compliance. Practice points: For patients with CLL with unmutated immunoglobulin variable heavy chain gene (IgVH), novel agents are the first therapy. Evidence is limited about the best treatment approach after relapse on venetoclax.  * * *  Initial work-up in patients with CLL The initial work-up for patients with CLL is often fluorescent in situ hybridization (FISH), looking for trisomy 12, as well as deletion of 13q, 17p, and 11q. Next-generation sequencing is used to look for mutations in TP53 and IgVH mutational analysis is done to recognize whether a patient is mutated. IgVH-mutated patients tend to respond better to therapy. When to treat Henry recommends the “if it bothers you, it bothers me” approach, noting that indications for treatment include fever, chills, night sweats, lumps and bumps in the neck, large liver and spleen, and high creatine. Progression If a patient is IgVH unmutated, that takes chemoimmunotherapy combinations off the table, regardless of whether the patient is young or fit. Instead, they are on a pathway to receive a novel agent as first therapy. The choices for novel agents keep expanding. Some standards include ibrutinib plus or minus obinutuzumab, venetoclax plus obinutuzumab, and acalabrutinib plus or minus obinutuzumab. Each of these combinations has different adverse event profiles and dose schedules. Patient preferences and comorbidities should drive decision making on novel combinations. Relapse The million-dollar question: What is the best treatment following relapse on venetoclax? The answer is unclear but there are generally two choices: Re-treat with the same regimen or switch to a Bruton’s tyrosine kinase (BTK) inhibitor. There are limited data on re-treatment and emerging data on BTK inhibitors after venetoclax that points to success. * * * 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  
Chimeric antigen receptor (CAR) T-cell therapy is one of the hottest advances in lymphoma treatment, but who should get it and what does the process look like? Allison Winter, MD, of the Cleveland Clinic helps answer those questions on the podcast. She joins Blood & Cancer host David H. Henry, MD, of the Pennsylvania Hospital, Philadelphia, to break down the side effects and look ahead to possible off-the-shelf products. In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, discusses optimism bias. She recalls a time when a patient’s drive for optimism affected what she told them and whether that was a good or bad thing.  Practice points: The time to refer a patient for CAR T-cell therapy is at relapse. CAR T-cell therapy side effects are serious and include cytokine release syndrome and neurotoxicity. CAR T-cell therapy use in lymphoma  For patients with diffuse large B-cell lymphoma, treatment after relapse typically involves salvage therapy, and if they are chemotherapy-sensitive, autologous transplant. The time to refer a patient for CAR T-cell therapy (or other clinical trial options) is at the time of relapse. CAR T cells are currently approved after two lines of therapy. What is the process for a patient to get CAR T-cell therapy? Evaluation by physicians. Approval of insurance. Collection of the patient’s T cells. Shipment of T cells for genetic modification (takes several weeks). Reception of genetically modified T cells by patients. Administration of lymphodepleting chemotherapy. Admission to the hospital for CAR T-cell infusion. The median time to get CAR T cells is 26 days. Allogeneic CAR T-cell products (called off-the-shelf) are in the clinical trial stage. The two major side effects of immunotherapy include cytokine release syndrome and neurotoxicity. Reference: Axicabtagene ciloleucel CAR T-cell therapy in refractory large B-cell lymphoma. N Engl J Med. 2017 Dec 28; 377:2531-44. *  *  * 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 David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz      
Understanding biosimilars

Understanding biosimilars

2020-02-0600:20:40

Think of biosimilars as your mother’s minestrone soup: It’s the same recipe and ingredients every time, but not every batch is chemically identical, even if it tastes about the same. That’s how Brian T. Hill, MD, PhD, of the Cleveland Clinic, describes biosimilars. He joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to discuss how biosimilars are made and approved, and how they differ from generic drugs.  In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about percentages -- what they mean, what they don’t mean, and how they can be interpreted in oncology.  * * * What are biosimilars? Monoclonal antibodies and biologics are complex and large proteins that are made in cells and bioreactors. Because they are made in “nature” instead of a synthetic reaction (discussed with generics), slight differences can be expected in the molecular structure.  Those slight variances do not create clinically meaningful differences between the biosimilar and the original product.  Biosimilars go through very stringent review by the Food and Drug Administration and head-to-head clinical trials with the originator drug.  Biosimilar vs. generic drug This is in contrast to a “generic” drug. In generic drugs, the chemical composition of all brands is synthesized identically.  An insurance company may approve a biosimilar, but not the originator drug.  Monoclonal biosimilars are on the way as the patent expires; this could soon mean that Herceptin (trastuzumab) will have a biosimilar.  Points: Insurance driven or otherwise, both Dr. Hill and Dr. Henry would be comfortable using biosimilars.  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
ASH19 special report

ASH19 special report

2020-01-3000:31:42

Blood & Cancer takes you behind the podium at the American Society of Hematology annual meeting for an in-depth look at the latest developments in anemia and myelodysplastic syndrome, chimeric antigen receptor (CAR) T-cell therapy for mantle cell lymphoma, use of novel agents in follicular lymphoma, and a range of new advances being explored in chronic lymphocytic leukemia. Guests on the podcast include Brian T. Hill, MD, PhD, and Allison Winter, MD, both with the Cleveland Clinic, and Anthony Mato, MD, and Lindsey E. Roeker, MD, of Memorial Sloan Kettering Cancer Center in New York. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about the gratitude that can come from surviving cancer. *  *  *  ASH19 abstracts discussed in this podcast: Abstract 843: Roxadustat in the treatment of anemia in patients with lower-risk myelodysplastic syndrome and low red blood cell transfusion burden. Abstract 754: (03:45) KTE:X19, an anti-CD19 CAR T-cell therapy in patients with relapsed/refractory mantle cell lymphoma: Results of the phase 2 ZUMA-2 trial. Abstract 3982: (08:28) Comparative outcomes of relapsed follicular lymphoma patients treated with novel agents: A multi-center analysis. Abstract 31: (13:45) ELEVATE TN: Phase 3 study of acalabrutinib combined with obinutuzumab or alone versus obinutuzumab plus chlorambucil in patients with treatment-naïve chronic lymphocytic leukemia. Abstract 33: (19:01) Ibrutinib and rituximab provides superior clinical outcome compared to FCR in younger patients with chronic lymphocytic leukemia: Extended follow-up from the E1912 trial. Abstract 36: Quantitative analysis of minimal residual disease shows high rates of undetectable MRD after fixed-duration chemotherapy-free treatment and serves as surrogate marker for progression-free survival: A prospective analysis of the randomized CLL14 trial. Abstract 355: Four-year analysis of Murano study confirms sustained benefit of time-limited venetoclax-rituximab in relapsed/refractory chronic lymphocytic leukemia. *  *  * 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
When it comes to treating pain related to sickle cell disease, consider the underlying factors, from constipation to compression spine deformity. That’s just some of the advice from Ifeyinwa Osunkwo, MD, of Atrium Health and Levine Cancer Institute in Charlotte, N.C. She joins host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to discuss her tips for treating pain and other complications of sickle cell disease. Dr. Osunkwo also provides an update on progress toward a cure in sickle cell disease that could be available to a large number of patients. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about why treating patients with cancer doesn’t make her sad. *  *  * Treating pain in sickle cell: In sickle cell disease, patients have acute episodes of vaso-occlusive crisis, as well as chronic pain. Consider whether the pain symptoms are an acute exacerbation of their chronic pain, an independent acute episode of pain, or chronic pain. In her practice, Dr. Osunkwo has moved to less chronic opioid use and more adjuvant use. She says treat the pain but look for the reason underlying it. The pain could be a result of bone damage, a compression spine deformity, constipation, or other factors related to their disease or the treatment. Consider the impact of opioid withdrawal after receiving a high dose in the hospital. Treating acute chest syndrome: Acute chest syndrome is usually not subtle in its presentation. It is acute and includes fever, pain, difficulty breathing or shortness of breath, hypoxia, and the patient looks sick. Consider their last chest x-ray and look for changes. Is this a new pulmonary infiltrate? This is a patient who should be transfused to get them out of distress. Most of acute chest syndrome cases happen 3 days into a hospital admission. Developments in sickle cell treatment: Two new drugs to treat sickle cell symptoms were approved in the United States in 2019: voxelotor (Oxbryta) to increase hemoglobin and crizanlizumab-tmca (Adakveo) to reduce the frequency of vaso-occlusive crisis. What is coming next? Researchers are working on potential cures for sickle cell that would be available to patients on a widespread basis. That includes haploidentical transplant and gene therapy. American Society of Hematology guidelines on the treatment of sickle cell complications. *  *  * 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
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 review the top three GI cancer trials presented at the 2019 ESMO World Congress on Gastrointestinal Cancer, and how they are changing practice.  Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about the difficulty in using age to guide cancer treatment.   *  *  * BEACON trial for colorectal cancer Patients with BRAF mutations have a poor prognosis and typically fail treatment prior to second line therapy. BEACON is a phase 3 trial that was designed to test BRAF/MEK combination targeted therapies in patients with BRAF-mutated metastatic colorectal cancer. The study found that the three-drug combination of encorafenib, binimetinib, and cetuximab significantly improved overall survival in patients with BRAF-mutated metastatic colorectal cancer. The response rate for targeted triple therapy was 26%, compared with 2% for controls. It may be important for all patients with colorectal cancer to be tested for BRAF. IDEA trial in colon cancer Use of oxaliplatin in chemotherapy treatment regimens results in improvement in outcomes for patents with stage III colon cancer. However, treatment with oxaliplatin can cause disabling neuropathy, which is directly proportional to the cumulative dose administered. The IDEA (International Duration Evaluation of Adjuvant Therapy) trial combines data from six trials, in which patients with stage III colon cancer were randomized to receive 3 months or 6 months of adjuvant chemotherapy with a fluoropyrimidine plus oxaliplatin. The incidence of peripheral neuropathy was significantly reduced with the 3-month regimen, as compared with 6- month treatment. Survival data for 3 months of treatment with oxaliplatin are still pending. In patients with positive circulating tumor DNA (ctDNA) prior to adjuvant therapy, 6 months of treatment was preferable. Pembrolizumab, plus or minus chemotherapy, in gastric cancer This was a well-balanced three-arm study which included groups of patients treated upfront with pembrolizumab alone, chemotherapy alone, or a combination of pembrolizumab with chemotherapy. The primary endpoint was overall survival. Pembrolizumab was noninferior to chemotherapy if the combined positive score (CPS) was greater than 1. Pembrolizumab plus chemotherapy was not superior, even for CPS greater than 0.85. When pembrolizumab is started alone, patients drop off quickly. However, the responders to pembrolizumab have a long duration of response. It may be beneficial to start with chemotherapy and switch to targeted therapy when the side effects of chemotherapy become too great. Show notes by Debika Biswal Shinohara, MD, PhD, 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
Thomas LeBlanc, MD, of Duke Cancer Institute in Durham, N.C., joins host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to discuss the evolution of the palliative care field and some of the underrecognized ways that it can improve care for hematology-oncology patients. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, shares the story of a patient who put aside her own desire for hospice because of family pressure to pursue curative treatment. *  *  * Palliative medicine has evolved tremendously over the past decade; it used to be synonymous with hospice and dying. It is now a sophisticated medical subspecialty with growing and large evidence base.  Palliative treatments are aimed at maximizing patient's quality of life and can be provided alongside other curative treatments.  Physicians, physician assistants, and nurse practitioners form an interdisciplinary team along with patients and their families.  Palliative care specialists can work alongside oncologists to optimize symptom management in patients with multiple or refractory/severe symptoms, including chemotherapy-induced nausea and pain neuropathy.  Palliative care specialists also can help provide a safe space and an extra layer of support to patients having difficulty coping with illness.  The American Society of Clinical Oncology (ASCO) has developed a guideline that all patients with advanced cancer should be receiving dedicated palliative care services concurrent with active treatment.  Workforce shortages in palliative care are limiting access for patients with cancer. Resource: Integration of palliative care into standard oncology care: ASCO Practice Guideline update (2017) Show notes by Debika Biswal Shinohara, MD, PhD, 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
In this special edition podcast, we bring you the best of Clinical Correlation, a segment on the human side of hematology-oncology care. Clinical Correlation is written, recorded, and produced by Ilana Yurkiewicz, MD, of Stanford (Calif.) University. This episode includes five of our favorite Clinical Correlation segments.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
In this special edition podcast, Blood & Cancer revisits an interview with Ilana Yurkiewicz, MD, of Stanford (Calif.) University. Dr. Yurkewicz is the writer and producer of the podcast’s Clinical Correlation segment, which puts a human face on hematology-oncology care. She sits down with MDedge producer Nick Andrews for a wide-ranging interview that covers everything from the best advice she’s ever gotten to her favorite science fiction writer. The interview first aired on our sister podcast, Postcall.   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
Howard “Skip” Burris, MD, chief medical officer of Sarah Cannon Cancer Institute in Nashville, Tenn., joins the podcast to talk about what it’s like to be the 2019-2020 president of the American Society of Clinical Oncology. Dr. Burris joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to share his priorities as president and how he finds the time for advocacy, research, and clinical practice. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, shares the story of a couple who had cancer at the same time.   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 Mintzer, MD, of the University of Pennsylvania, Philadelphia, joins the podcast to discuss noteworthy drug approvals in hematology-oncology in 2019. Dr. Mintzer and Blood & Cancer host, David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, discuss what these new treatment options mean for clinicians and patients. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, is at the annual meeting of the American Society of Hematology with a reminder that the way we talk about patients matters. *  *  *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * *  Dr. Mintzer’s review of new drug approvals in 2019: https://www.mdedge.com/hematology-oncology/article/211340/mixed-topics/2019-glance-hem-onc-us-drug-approvals?channel=27979 More articles on FDA approvals in hematology-oncology: https://www.mdedge.com/hematology-oncology/news-fda/cdc * * *  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
Matt Kalaycio, MD, of the Cleveland Clinic joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to preview the potentially practice changing research that will be reported at the 2019 annual meeting of the American Society of Hematology. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, addresses the isolation that comes from dealing with a serious chronic illness, especially around the holidays. *  *  *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *  FDA approves atezolizumab combo as first line for advanced NSCLC Atezolizumab is a monoclonal antibody and is already approved for adults with metastatic NSCLC with disease progression. By Laura Nicolaides The Food and Drug administration as approved atezolizumab in combination with paclitaxel and carboplatin chemotherapy for first-line treatment of adults with metastatic, nonsquamous non-small cell lung cancer with no EGFR or ALK genomic tumor aberrations.  *  *  *  ASH abstracts discussed in the podcast: Abstract 1: Post-transplantation cyclophosphamide after allogeneic hematopoietic stem cell transplantation: Results of the prospective randomized HOVON-96 trial in recipients of matched related and unrelated donors. Abstract 261: Superior survival with post-remission pediatric-inspired chemotherapy compared to myeloablative allogeneic hematopoietic cell transplantation in adolescents and young adults with Ph-negative acute lymphoblastic leukemia in first complete remission: Comparison of CALGB 10403 to patients reported to the CIBMTR. Abstract 322: Nonmyeloablative allogeneic transplantation confers an overall survival benefit with similar nonrelapse mortality when compared with autologous stem transplantation for patients with relapsed follicular lymphoma. Abstract 6: Mosunetuzumab induces complete remissions in poor prognosis non-Hodgkin lymphoma patients, including those who are resistant to or relapsing after chimeric antigen receptor T-cell therapies, and is active in treatment through multiple lines. Abstract LBA-5: Validation of BCL11A as therapeutic target in sickle cell disease: Results from the adult cohort of a pilot/feasibility gene therapy trial inducing sustained expression of fetal hemoglobin using posttranscriptional gene silencing. Abstract LBA-6: Carfilzomib, dexamethasone, and daratumumab versus carfilzomib and dexamethasone for the treatment of patients with relapsed or refractory multiple myeloma: Primary analysis results from the randomized, open-label, phase 3 study Candor. Abstract 1588: A randomized trial of EPOCH-based chemotherapy with vorinostat for highly aggressive HIV-associated lymphomas: Updated results evaluating the impact of diagnosis-to-treatment interval and pre-protocol systemic therapy on outcomes. Abstract 940: Elucidating the role of IL6 in stress erythropoiesis and in the development of anemia under inflammatory conditions. Abstract 57: Patient harm from repetitive blood draws and blood waste in the ICU: A retrospective cohort study. Abstract 59: Impact of iron supplementation on patient outcomes in women undergoing gynecologic procedures: Systematic review and meta-analysis of randomized trials. Abstract 126: Polatuzumab vedotin plus obinutuzumab and lenalidomide in patients with relapsed/refractory follicular lymphoma: Primary analysis of the full efficacy population in a phase Ib/II trial. Abstract 168: Risk of hemorrhage in patient with polycythemia vera exposed to aspirin in combination with anticoagulants: Results of a prospective, multicenter, observational cohort study (REVEAL). Abstract 326: Safety and effectiveness of apixaban, LMWH, and warfarin among venous thromboembolism patients with active cancer: A retrospective analysis using four U.S. claims databases. Abstract 327: Safety and effectiveness of apixaban, LMWH and warfarin among venous thromboembolism patients with active cancer: A subgroup analysis of VTE risk scale. Abstract 566: Phase II study of oral rigosertib combined with azacytidine as first line therapy in patients with higher-risk myelodysplastic syndromes.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
In this special edition podcast, Blood & Cancer revisits an interview with Gary H. Lyman, MD, of Fred Hutchinson Cancer Research Center, Seattle, on defining and understanding biosimilars. Dr. Lyman joins host David H. Henry, MD, to explore the interchangeability of these drugs and how biosimilars are being integrated into clinical practice guidelines. *  *  *   Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *   This Week in Oncology ASH preview: Key themes include tackling CAR T obstacles, sickle cell advances, VTE By Sharon Worcester Chimeric antigen receptor (CAR) T-cell therapies have garnered a great deal of attention given their “incredible efficacy” in treating B-cell malignancies, and new findings are taking aim at the drawbacks of therapy, such as the time, expense, and toxicity involved. *  *  *   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
Jame Abraham, MD, of the Cleveland Clinic joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia to review two cases of breast cancer, focusing on when to use the 21-gene Oncotype DX breast recurrence score and how to apply the results.   Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, explores what happens when the patient minimizes their symptoms in order to keep getting treatment. *  *  *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *  This Week in Oncology Not all lung cancer patients receive treatment By Richard Franki In the United States, just over 15% of patients with lung cancer receive no treatment, according to the American Lung Association. *  *  *  Breast cancer cases Case 1: A 46-year-old, premenopausal woman who has had a right breast lumpectomy with a 7-mm tumor that is invasive ductal, ER/PR positive, and HER2 negative. Since her tumor is small and low grade, would you do Oncotype DX recurrence score testing? Dr. Abraham recommends: Explain to the patient that her benefit from chemotherapy will be limited, but that she meets the tumor size requirement for the Oncotype DX assay and offer her the test. Case 2: A 57-year-old women who is postmenopausal with a grade 1 tumor that is 10mm, ER/PR positive, HER2 negative, with 4 of 17 positive lymph nodes. Is there an advantage to adding the Oncotype DX testing for this patient? Dr. Abraham recommends: Offer the patient chemotherapy; recommend against Oncotype DX testing. Show notes by Mary Ellen Schneider   References Sparano JA et al. Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med. 2018 Jul 12;379(2):111-21. Sparano JA et al. Clinical and genomic risk to guide the use of adjuvant therapy for breast cancer. N Engl J Med. 2019 Jun 20;380(25):2395-2405. *  *  *  For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
Jack West, MD, joins the podcast to discuss the immunotherapy in the treatment of lung cancer. Dr. West is an associate clinical professor in medical oncology at City of Hope Comprehensive Cancer Center in Duarte, Calif., and a thought leader in thoracic oncology. Dr. West and Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, discuss assays, liquid biopsy, and review a recent case in part two of their interview. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, reminds us that even when just “covering” a patient for another physician, you could be in for some difficult discussions. *  *  *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *  This Week in Oncology Atezolizumab bests chemo in NSCLC patients with high PD-L1 expression by Jennifer Smith Atezolizumab monotherapy can improve overall survival in treatment-naive patients with stage IV non-small cell lung cancer and high PD-L1 expression according to the results of a phase 3 trial presented at the 2019 annual meeting of the Society for Immunotherapy of Cancer. Assays Important to rapidly test for PDL1, EGFR and ALK status and have all results before committing to first-line therapy. PDL1 testing results often take 24 hours, while EGFR and ALK results can take several weeks; committing to immunotherapy without knowing the status of molecular drivers is not ideal. Liquid biopsy Measures DNA from tumor cells circulating in the blood. Testing takes about a week. A positive result can be trusted. A negative result cannot be trusted, given low sensitivity, especially in patients with low tumor burden. Adverse effects of immunotherapy Striking variability in toxicity profiles among patients. Although overall better tolerated than chemotherapy, the “unknown” aspect of immunotherapy toxicities may be anxiety provoking for patients. Fatigue, rash, and thyroid abnormalities are most commonly seen. However, there is a broad array of toxicities that oncologists may not be familiar with, necessitating a multidisciplinary approach. Case discussion An otherwise healthy, middle-aged woman presents with two lung nodules: a 1.4 cm lesion in the left upper lobe, and a 3.1 cm lesion in the left lower lobe. Both are biopsy proven to be non–small cell adenocarcinoma. Both lesions are excised with clear margins. There is no lymph node, vascular, or pleural invasion. In this case, it makes sense to view these as two independent cancers. Unclear if the chance of recurrence is increased based on the presence of two, less than 4 cm lesions with negative prognostic features and adequate excision with clear margins. The anticipated benefit of adjuvant chemotherapy must be weighed against toxicities, and the individual patient’s ability to tolerate chemotherapy must be considered. Resources Dr. West’s cancer education website for patients and caregivers: cancergrace.org Show notes by Sugandha Landy, MD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. *  *  *  For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
  H. Jack West, MD, joins the podcast to discuss the latest trials of immunotherapies in the treatment of lung cancer. Dr. West is an associate clinical professor in medical oncology at City of Hope Comprehensive Cancer Center in Duarte, Calif., and a thought leader in thoracic oncology. Dr. West and Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, review Keynote-042, Keynote-189, and IMpower150, and discuss how the findings influence practice. You can find Dr. West on Twitter at @JackWestMD. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, discusses how to be nonjudgmental when talking to patients about how they got cancer. * * * Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * * This Week in Oncology: FDA Approves Ziextenzo for neutropenia-related infection reduction The FDA has approved the biosimilar Ziextenzo to reduce the incidence of infection in patients with nonmyeloid cancer who are receiving suppressive anticancer drugs that are associated with febrile neutropenia. Treatment for metastatic nonsquamous non–small cell lung cancer (NSCLC) without EGFR mutation or ALK translocation: Keynote-042 Design: Pembrolizumab alone vs. chemotherapy alone (carboplatin plus paclitaxel or carboplatin plus pemetrexed) 902 patients 1:1 randomization All patients with at least 1% PDL1 positivity Stratified into three groups: greater than 1%, greater than 20%, and greater than 50% PDL1 score No crossover permitted between groups Results: Overall survival is 16.7 months with pembrolizumab vs. 12.1 months with chemotherapy. PDL1 score 1% or greater: 16.7 months for pembrolizumab vs. 12.1 months for chemotherapy alone. PDL1 score 20% or greater: 17.7 months for pembrolizumab vs. 13.0 months for chemotherapy alone. PDL1 score 50% or greater: 20.0 months for pembrolizumab vs. 12.2 months for chemotherapy alone. There was no statistically significant difference in progression-free survival. Conclusion: Pembrolizumab monotherapy can be extended as first-line therapy to patients with locally advanced or metastatic non–small cell lung cancer and a high PDL1 score. Pembrolizumab monotherapy alone may not be the best choice for patients with a low PLD1 score.   Keynote-189 Design: Pembrolizumab plus chemotherapy vs. placebo plus chemotherapy (pemetrexed plus platinum agent) 616 patients 2:1 randomization All patients with at least 1% PDL1 positivity Crossover to pembrolizumab monotherapy was permitted among the patients in the placebo-combination group who had verified disease progression Results: Overall survival to 12 months: 69.2% with pembrolizumab plus chemotherapy vs. 49.4% with chemotherapy alone. Progression-free survival: 8.8 months with pembrolizumab plus chemotherapy vs. 4.9 months with chemotherapy alone. Conclusion: Pembrolizumab should be added to standard chemotherapy of pemetrexed and a platinum-based drug for significantly longer overall survival and progression-free survival than chemotherapy alone, regardless of level of PDL1 positivity.   IMpower150 Design: Atezolizumab plus bevacizumab plus carboplatin plus paclitaxel (ABCP) vs. bevacizumab plus carboplatin plus paclitaxel (BCP) vs. atezolizumab plus carboplatin plus paclitaxel (ACP) 1,202 patients 1:1:1 randomization Patients with any PD-L1 immunohistochemistry status were eligible Stratified by level of Teff gene-signature expression Results: Overall survival was longer in the ABCP group than in the BCP group (19.2 months vs. 14.7 months). Progression-free survival was longer in the ABCP group than in the BCP group (8.3 months vs. 6.8 months). In the Teff-high population, progression-free survival was significantly longer in the ABCP group than in the BCP group (11.3 months vs. 6.8 months). Conclusion: Addition of atezolizumab to bevacizumab plus chemotherapy significantly improved progression-free survival and overall survival among patients with metastatic nonsquamous NSCLC, regardless of PD-L1 expression. Unclear if ABCP regimen is superior to pembrolizumab monotherapy (in greater than 50% PDL1 group) or pembrolizumab plus pemetrexed plus platinum agent (in all PDL1 groups) as a four-drug regimen may be less attractive than these options. Teff status has not yet been proven to be useful for clinical decision making.   References Mok TSK et al. Pembrolizumab versus chemotherapy for previously untreated, PD-L1-expressing, locally advanced or metastatic non–small cell lung cancer (KEYNOTE-042): A randomised, open-label, controlled, phase 3 trial. Lancet. 2019;393:1819-30.   Gandhi L et al. Pembrolizumab plus chemotherapy in metastatic non–small cell lung cancer. N Engl J Med. 2018;378:2078-92. Socinski MA et al. Atezolizumab for first-line treatment of metastatic nonsquamous NSCLC. N Engl J Med. 2018;378:2288-301.   Show notes by Sugandha Landy, MD, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
David L. Streiner, PhD, of McMaster University, Hamilton, Ont., and the University of Toronto, joins Blood & Cancer host David Henry, MD, of Pennsylvania Hospital, Philadelphia, to explain what a post hoc analysis is and why it should be interpreted with caution. Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, explores what to tell patients when it comes to prognostic scoring system results. * * *  Help us make this podcast better! Please take our short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 * * *  This week in Oncology: In rectal cancer, fragmented care linked to lower survival by Jim Kling, reporting from Clinical Congress 2019. Post hoc analyses What is a post hoc analysis? Analyzing data after a study has already had conclusions made and looking for patterns that were not prespecified. Dr. Streiner’s advice for researchers: Pick a small number of primary outcomes and develop a narrow hypothesis. Then use post hoc analysis as a means of assessing future questions that can be investigated in a subsequent study. Dr. Streiner’s advice for clinicians: Treat a post hoc analysis as a hypothesis that requires further study. It should be viewed with some degree of suspicion because it may have been significant only by chance. Show notes by Ronak Mistry, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.   References Marcus R et al. Obinutuzumab for the first-line treatment of follicular lymphoma. N Engl J Med. 2017;377:1331-44. Crawford ED et al. Comorbidity and mortality results from a randomized prostate cancer screening trial. J Clin Oncol. 2011;29:355-61. Streiner DL et al. Size, follow-up, data analysis – good; post hoc analysis, interpretation – not so good. Commun Oncol. 2011;8:379-80.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
Strategies and guidelines for delivering bad news to patients from David Henry, MD, and Ilana Yurkiewicz, MD.  Timestamps: This week in Oncology (01:30) Conversation (04:22) This week, the host of Blood & Cancer and the writer, producer, and talent behind the Clinical Correlation segment sit down together for the first time ever.  Dr. Henry and Dr. Yurkiewicz share strategies and anecdotes about their experiences learning how to give patients terrible news and --perhaps more importantly -- how not to.  Links: SPIKES mnemonic Dr. Henry: Academic Biography Dr. Yurkiewicz Academic Biography Hard Questions column This week in Oncology.  Immunotherapy enables nephrectomy with good outcomes in advanced RCCby Susan London Some patients with advanced renal cell carcinoma treated with immune checkpoint inhibitors can safely undergo nephrectomy and experience favorable surgical outcomes and pathologic responses according to a cohort study from Urologic Oncology.  SOURCE: Singla N et al. Urol Oncol. 2019 Sep 12. doi: 10.1016/j.urolonc.2019.08.012 For more MDedge podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter @mdedgehemonc David Henry on Twitter @davidhenrymd Ilana Yurkiewicz on Twitter @ilanayurkiewicz  
Justine V. Cohen, DO, of the University of Pennsylvania, Philadelphia, joins Blood & Cancer host David H. Henry, MD, also of the University of Pennsylvania, to discuss a recent melanoma case in the adjuvant setting and when to consider targeted therapies or immune checkpoint inhibitors for these patients.  Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about what happens when a patient’s anxiety threatens to get in the way of the clinician’s decision making. Time stamps: Meet the guest (00:51) This Week in Oncology (03:02) Interview with Dr. Justine Cohen (05:48) Clinical Correlation (26:25) This week in Oncology FDA approves rivaroxaban for VTE prevention in hospitalized, acutely ill patients by Lucas Franki FDA approval for the new indication is based on results from the phase 3 MAGELLAN and MARINER trials, which included more than 20,000 hospitalized, acutely ill patients. Therapies for melanoma Classes of therapies for adjuvant melanoma include immune checkpoint inhibitors and targeted therapies. Historically, high-dose interferon was the only available therapy for melanoma. This was associated with a lot of toxicities, without great benefits in terms of overall survival. About 50% of melanomas are BRAF mutated and amendable to adjuvant treatment with the combination of BRAF/MEK inhibitors. Immunotherapy can be used in BRAF mutated patients or BRAF wild type (no mutation). Ipilimumab (anti-CTLA4) demonstrated recurrence-free survival benefit and an overall survival benefit. Toxicity = grade 3 or grade 4 immune-related side effects. Nivolumab and pembrolizumab (anti-PD1) have taken the place of ipilimumab. They are associated with lower rates of toxicities (14%-15%). Side effects of immunotherapy: “itis” (fever, ocular toxicity, lung, colon, rash, many others). These side effects may persist despite cessation of immunotherapy unlike targeted therapies, in which side effects resolve after stopping. Treatment decisions following adverse events depend on how much therapy is delivered prior to the event and the severity of toxicity.   Drug Class Mechanism of action Interferon Antiviral ·   Inhibits protein synthesis ·   Inactivates viral RNA ·   Enhances phagocytic and  cytotoxic mechanisms   Ipilimumab Checkpoint inhibitor ·   IgG1 monoclonal antibody against cytotoxic T-lymphocyte antigen 4   Nivolumab Checkpoint inhibitor ·   Human IgG4 monoclonal antibody against programmed death 1 (PD-1)   Pembrolizumab Checkpoint inhibitor ·   Human IgG4 monoclonal antibody against programmed death 1 (PD-1) Dabrafenib Targeted therapy ·   BRAF inhibitor   Vemurafenib Targeted therapy ·   BRAF inhibitor Trametinib Targeted therapy ·   MEK inhibitor    Show notes by Emily Bryer, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia. References Weber J et al. Adjuvant nivolumab versus ipilimumab in resected stage III or IV melanoma. N Engl J Med. 2017;377:1824-35. Eggermont AMM et al. Adjuvant pembrolizumab versus placebo in resected stage III melanoma. N Engl J Med. 2018;378:1789-1801. Long GV et al. Adjuvant dabrafenib plus trametinib in stage III BRAF-mutated melanoma. N Engl J Med. 2017;377:1813-23.   For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc Ilana Yurkiewicz on Twitter: @ilanayurkiewicz  
In this edition, we conclude our 3-part series about having hard conversations with patients as a trainee. This week's case poses the following question: "What would you do if this were your family member?" Ilana Yurkiewicz, MD, Blood & Cancer cohost and producer of the Clinical Correlation segment, is joined by the two residents who have been behind the Blood & Cancer show notes from the beginning, Emily Bryer, DO, and Ronak Mistry, DO, both of the University of Pennsylvania, Philadelphia. David H. Henry, MD, editor in chief of MDedge Hematology-Oncology and the host of Blood & Cancer, joins the podcast to talk about whether multiple myeloma patients with should receive maintenance therapy until progression.  Timestamps: TBD Dr. Henry's on difficult conversations (01:15) This week in Oncology (04:17) Difficult conversations for trainees part III (06:37) Links: This week in Oncology What is the optimal duration of maintenance in myeloma? Ilana Yurkiewicz, MD Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University.  Hard Questions Emily Bryer, DO Ronak Mistry, DO   For more MDedge podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd Ilana Yurkiewicz on Twitter: @ilanayurkiewicz
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