Notable News: September 2018

Since smoking is the leading cause of preventable disease and death worldwide, reports about it don’t usually contain good news, but this month they do. The International Association for the Study of Lung Cancer (IASLC) is convening in Toronto, Canada this week for the 19th World Conference on Lung Cancer #WCLC2018, and the importance of screening is being emphasized. Data coming out of the conference shows that CT screening reduces lung cancer deaths by 39% in women and 24% in men. Cdc.gov says the only recommended screening for lung cancer is low-dose computed tomography (also, low-dose CT scan or LDCT). Yearly lung cancer screenings are recommended for people who have a history of heavy smoking, smoke now or have quit in the past 15 years, and are between 55 and 80 years old. So, if you are at risk, make sure you are getting screened! Also, you can find the cdc.gov fact sheet about smoking here.

Another study shows that smoking might not remain the leading cause of preventable disease and death, but something else is going to take it’s place. Right now smoking is the leading cause of preventable cancer among women in the United Kingdom, but that is set to change, reports cnn.com. Thanks to a reduction in smoking and an increase in body weight, obesity will be the leading cause of cancer in women by 2043 if current trends continue. The news is particularly alarming because obesity can also cause some cancers, including breast cancer, to spread. Data collected between 1979 and 2014 was analyzed to determine the projections. Campaigns highlighting smoking risks are credited with the reduction in smoking-related cancers, and researchers are suggesting similar campaigns about the risk of obesity be implemented. More information can be found here. These findings aren’t unique to the UK; this report from November 2017 shows similar trends in the United States.

Obese or not, the quality of your food can increase your risk for cancer, reports medicalnewstoday.com. A study done in Paris shows that regular consumption of food low in nutritional value increases cancer risk. Of the 471,495 participants in the study, 49,794 had been diagnosed with cancer. More specifically, the findings showed men had an increased risk for colorectal cancer, cancer of the upper aerodigestive tract and stomach, and lung cancer. Women showed an increased risk for liver cancer and postmenopausal breast cancer. The research is being used to support the enforcement of a food-labeling system that would clearly state nutritional value of products. Learn more about the study and the food-labeling system here.

More good news comes this month in the form of new information. A study reported in cancer.gov reveals that cancer of the appendix, while usually given the same chemotherapy treatments, is actually quite different from colorectal cancer and other gastrointestinal cancers. The study also showed that the type of gene mutations present in appendiceal cancers could serve as an indicator for a patient’s prognosis. While the study isn’t likely to change practice yet, the information does provide helpful information about a rare cancer, and it indicates a need to develop treatments based on each specific cancer subtype. Much more detailed and technical information about the study findings and appendiceal cancers can be found here.

Finally, there are a couple of stories that happened this month that are worth sharing because they emphasize the poignancy of National Childhood Cancer Awareness Month in a way that little else could. The first is a love story about a couple that recently got married on the grounds of St. Jude’s Children’s Research Hospital. The bride and groom are both childhood cancer survivors who met at St. Jude’s while undergoing treatment 25 years ago. They lost touch over the years, but they were reunited when they both accepted jobs at St. Jude’s, and they rekindled their childhood friendship. Their friendship blossomed into love, and this couple of survivors chose September 1, the first day of Childhood Cancer Awareness Month, as their special day. Read more about the couple’s big day here. Bonus: there’s a video!

The second story is a different kind of love story. It’s about two-year-old Brody Allen. Brody has terminal brain cancer, and he loves Christmas. Brody isn’t expected to make it to Christmas this year so his parents decided to celebrate Christmas early. They put up a tree, and they put up outdoor decorations. Then, their neighbors started to decorate, too. Soon, the whole town was in on it and, earlier this week, Brody’s hometown put on a full-on, life-size Christmas parade in his honor, complete with super heroes and Santa Claus. You can read more about Brody here and see clips from his parade here. Merry Christmas, Brody.

How to Pay for Long-term Care on a Fixed Budget

Long-term care costs are rising yearly, and with more people approaching age 65+ than ever before, the rates are not expected to fall. Not everyone plans ahead and unfortunately, we cannot know for certain when someone will begin to need long-term care, as it varies case by case. For the elderly population specifically, many individuals begin long-term-care after a sudden life change that renders them incapable of caring for themselves, like a stroke or a fall. In the best-case scenario for a stroke or a fall, patients return home after successful rehabilitation. However, as unfortunate as it may be, many individuals are unable to return to their former health.

Sometimes, there is no sudden change and it is simply advanced age that is the main factor determining whether or not a person can safely remain independent. When someone does begin to need-long-term care, depending upon the severity of the person’s situation, they are either taken care of by professional caregivers, family members, or moved into an institutional setting. Statistically speaking, about 80% of elderly people who need long-term care receive services within their own home or the home of a family member. The remaining 20% move into facilities, specially designed to accommodate a wide range of needs. Regardless of where we choose to spend our twilight years, there are costs involved. Below, I’ll outline some common ways people are able to fund their long-term care.

What Exactly is Long-term Care?

Long-term care simply refers to the type of assistance provided to people with cognitive or functional limitations to help them perform daily activities. If patients are unable to return safely home after a hospital stay, facilities continue rehabilitation to try and strengthen patients and improve their quality of life. The more a resident can do by himself or herself (eating, using the bathroom, bathing, and changing), the happier they generally are.

According to the Medicare Current Beneficiary Survey, the elderly population in nursing homes has declined over the past ten years. Through more advanced rehabilitation practices and an increased availability to services, the majority of long-term care recipients are able to live with loved ones, in assisted living, or group homes if they do not need the intensive 24hour supervision that comes along with nursing home residence. Nevertheless, the question still remains: how to pay for the care you need.

Medicaid Long-term Care:

For many people, Medicaid is the best option when it comes time to pay for long-term care. If your loved one meets certain medical and financial requirements, or they are already receiving SSI benefits, they may be eligible. For most states, the monthly income limit is around $2,200 and the asset limit is $2,000. For Arizona specifically, the monthly income limit is $2,205. Anything beyond these values needs to be spent towards care or the applicant may be ineligible. The medical eligibility is stringent and the recipient can only live in Medicaid approved homes or receive Medicaid approved services in the community. Even with all of the requirements, this is still the best option for many families. For up-to-date Medicaid information, follow this link.

Long-term Care Insurance:

Although a person may have paid for medical insurance their whole life, medical insurance companies do not cover long-term care. There is, however, such a thing as long-term care insurance. There are different policies with different features, but generally, a person pays a monthly premium and when long-term care services are needed, the policy will pay out a certain amount, usually in the hundreds of thousands. Similar to life insurance, premiums are cheaper if the person buying insurance is young and healthy. Those already in need of long-term care services are not able to get coverage. Although these policies do not last forever, the payout is usually sufficient for the entire cost of care.

Sometimes, however, the care outlasts the insurance coverage. Don’t worry because many states have what is called a long-term care insurance partnership, useful when people spend through their policy and need to apply for Medicaid coverage. The partnership is a program between the state and private insurance companies. Partnership policies protect assets by reciprocating dollar for dollar what policyholders pay into their policies. For example, if you bought a Partnership Policy with a maximum benefit payout of $200,000, you are able to protect $200,000 of your assets. For married couples each spouse needs to purchase their own policy.

Once the original long-term care insurance coverage is exhausted, you may apply for Medicaid with the benefit pay out’s worth of assets exempted. This is extremely beneficial because again, most states have an asset limit of $2,000. In addition to the asset limit, Medicaid penalizes people who have given away or sold property below fair market value within the five years preceding the need for long-term care assistance.

Qualified Income Trust:

If an individual is over the financial limit for Medicaid long-term care coverage, some states allow applicants to spend down income towards medical care while others allow the creation of Qualified Income Trusts, also known as Miller Trusts. Miller Trusts place any income beyond the state’s limit into a trust, designating the state Medicaid program as the beneficiary once the long-term care recipient dies. The problem many people have with spend-down and Qualified Income Trusts is that for the most part, all assets and income eventually go towards care. Long-term care insurance, as described above, helps prevent the complete drain of assets for people who are hoping to leave behind a legacy.

Reverse Mortgage:

Another option that has gained popularity in recent years is the reverse mortgage. A reverse mortgage is not complicated, but may not be the best option for every situation. Essentially, a reverse mortgage is a loan borrowed against the equity of a home, but rather than making monthly payments, the bank reversely pays the borrower. As long as the borrower remains in the home they do not have to pay the bank.

If the borrower moves to a care facility or passes away, then the bank claims the property to pay off the amount given in the loan. This is a good option if the homeowner is healthy enough to remain at home, but requires some caregiving services. Also, this is for people who are not interested in leaving their home behind to loved ones. See here for a more detailed explanation of pros and cons.

Even with 80% of elders receiving “free” care through informal caretakers such as family members, the Congressional Budget Office estimates the value of this donated care at approximately $234 billion for 2011, the last year calculated.[1] This number is determined based on calculating forgone wages, time that could be spent employed elsewhere, transportation costs, and performing duties otherwise performed by paid healthcare aids.

For family caregivers it is especially important to reach out to a social worker for benefits you may not be aware of in your home state. If you are a family caretaker, your loved one may be eligible for respite care, a paid-for medical alert, home health services, or community based waivers paid for by Medicaid depending on financial and medical eligibility. Don’t wait until it is too late and start planning today.


[1] See page 2. http://www.cbo.gov/sites/default/files/44363-LTC.pdf

 

Patient Profile: Jack Bell

Jack Bell

Hepatoblastoma

Today, Jack Bell is a 13-year-old 8th grader. He’s the second of four siblings, and he’s a generally happy kid. While he doesn’t remember much about it, he is also a childhood cancer survivor. Along with Jack, there are more than 400,000 childhood cancer survivors in the United States, and that number is growing. Over the past 40 years, cancer death rates in children have declined 70 percent. However, with cancer still the leading cause of death from disease among people under age 19, a childhood cancer diagnosis is difficult for the entire family.

“It was not a good time. It really wasn’t,” says Rachel Bell, Jack’s mom, remembering his diagnosis. It was late December 2007. She was expecting her third child in a couple of months and preparing for New Year’s Eve guests, but when Jack, an active two and a half year old, took a four hour nap while she was putting away the Christmas decorations, she took notice. There were other things, too. He fell asleep during a shopping trip to Costco, and Rachel’s husband Ed, who was in charge of bath time, had noticed a protrusion in Jack’s abdomen. With a doctor’s visit coming up, they planned to have it all checked out, but they didn’t have a chance. Jack woke up screaming the morning of New Year’s Eve, and he just wouldn’t calm down. They called the doctor’s office, but were advised to go to the emergency room, where Jack was checked for mono, appendicitis and cystic fibrosis. “They kept ruling things out,” Rachel says, adding that the list of possible illnesses kept getting worse. Unable to determine the cause, Jack was admitted for more testing.It was the next day, New Year’s Day, that Jack’s pediatrician told Rachel and Ed that Jack had cancer.

Jack Bell during chemotherapy, age 2

“It went fast from that point,” says Rachel. “You’re in a completely new world.” Jack had stage four hepatoblastoma that originated in his liver and had spread to both lungs. Hepatoblastoma is a very rare type of malignant tumor, and the exact cause is unknown. Rachel says that in Jack’s case, doctor’s believed it was a fetal mutation in which his liver didn’t stop growing when it should have. Jack had surgery that day. He had multiple masses in both lungs and one in his liver the size of a watermelon. That’s what was pushing his ribs out causing the protrusion in his abdomen.

Jack’s chemotherapy started January 9, and they were making weekly trips to the hospital. They were in and out of the hospital a lot during that time. Anytime Jack had a fever they had to go to the hospital. Just as they were adjusting to their new world, they got another surprise. Though she was not due until February 28th, Rachel went into labor February 5th, and their third son, Sam, was born. Within five hours of coming home with the new baby, they were back in the hospital with Jack who had a fever.

“It was chaos,” says Rachel. She had a new born, a two year old with cancer, and Charlie, her oldest, was five and in kindergarten. In addition, Jack was sick from the chemo and losing his hair. After the second round of chemo they learned that the tumors in Jack’s lungs were gone and the one in his liver had shrunk 50 percent, but it was wrapped around a main artery, and Jack needed a liver transplant. “I just wanted someone to tell me that he was going to be okay,” says Rachel, but no one could do that. Rachel and Ed learned that without the transplant surgery, Jack had only a ten percent chance of survival. With the surgery his survival rate went up to 85 or 90 percent.

Jack got on the transplant list on April 1, but there were indications that the cancer was spreading. Jack’s Alpha-Fetoprotein (AFP) numbers were going up. The AFP numbers serve as a marker for liver health. Normal levels are below ten; Jack’s had been 365,000. Doctors were unable to determine if and where the cancer was spreading, but if it was, it could jeopardize the transplant surgery. So, Jack was moved to emergency transplant status May 1. Rachel, Jack, Ed and Baby Sam had to be ready to leave for the transplant hospital at a moment’s notice. They had to have air transportation available, and arrangements for someone to care for Charlie. “We had to wear a beeper and be ready to leave at any time,” says Rachel, who adds that they were willing to jump through whatever hoops they had to or try just about anything to help Jack. “If they tell you to stand in the street and throw glitter in the air and sing a song, you’re going to do it four times a day,” she says.

On Mother’s Day that year Rachel remembers praying for a liver for Jack, but also being acutely aware that his liver would come from another child, and she grieved for the mother that would be losing her child. It was three days later, May 14, at 3 a.m. while she was nursing Sam, that they got the beep. They had a liver and had to leave immediately. Jack was prepped for surgery which went through the night and ended May 15. The doctors discovered that Jack’s AFP numbers had been correct; the tumor was growing, but it was contained to his liver so it did not affect the transplant. The surgery went very well. Jack was a perfect match to his donor, and they were home by June.

Jack Bell after his liver transplant, age 3

Jack, who turned three during his liver transplant recovery, recently celebrated being ten years cancer free. “Thankfully, he doesn’t remember much,” says Rachel adding that Jack does seem to be very in tune with his health for his age.“He does know a lot about his liver,” she says. Like other childhood cancer survivors, Jack will spend the rest of his life being monitored. Every two months he returns to the hospital for blood work. “I am constantly watching the AFP number,” says Rachel, who adds that after transplant surgery, Jack’s AFP went down to 12, and then to two, and that it has held at two ever since. He also takes immune suppressant medications to prevent his immune system from attacking and rejecting his liver, which has happened twice in the past decade. Jack also has a yearly cancer check that looks for late effects of the chemotherapy which are common among childhood cancer patients due to the effects of treatment on growing bodies. Rachel says that so far, any sign of late effects in Jack, which include some hearing loss, are minimal compared to what could have happened. Late effects can be physical, emotional, and/or cognitive and vary in degrees of severity. “It changes your whole attitude about what is important,” says Rachel.

In 2009, the Bell family welcomed their fourth child, Anna Kate. She is nine now. Sam is 10, and Charlie is 15. Even though Jack doesn’t remember much about his diagnosis and treatment, Rachel says it has definitely shaped who he is. Over the years Jack has become very close with his doctors and nurses and considers them part of his family. He even says that one day he’d like to be a doctor who specializes in the liver. “It’s important for these kids that survive to know how lucky they are,” says Rachel. “There will be a day he understands how serious it was and maybe he’s starting to realize that now.”

Coincidentally, while Jack was recovering from his transplant in May 2008, the United States Senate declared September 13 National Childhood Cancer Awareness Day. Later in 2012, September was made National Childhood Cancer Awareness Month. The proclamation states, “This month, we remember the young lives taken too soon, stand with the families facing childhood cancer today, and rededicate ourselves to combating this terrible illness.”

From left transplant surgeon, Dr. Frederick Ryckman, Survivor Jack Bell, Rachel Bell, and oncologist, Dr. Emad Salman. Rachel says, “I love any chance we get to be with these two docs!”


Sources:

https://www.cancer.gov/types/childhood-cancers

https://www.acco.org/childhood-cancer-awareness-month/

A Patient Engagement Manifesto– 6 Principles of Partnership

Recently I presented at a conference on the topic of patient engagement. I spoke to the audience, mainly comprised of digital technology start-ups, about the need to find ways to engage patients meaningfully in healthcare design.  Too many developers think they understand what patients need, but in reality, many appear to be motivated more by the cleverness of a technology than actual improvements in health outcomes.  A 2015 study from the New York University School of Medicine Department of Population Health reported that only 29% of smartphone owners using health apps say the apps have made a big impact on their health.

In thinking about this month’s blog topic, it occurred to me that it might be useful to have some guiding principles you can turn to when you are next called upon to take on a patient advisory role. Whether it’s a clinical trial, a new app, or improving hospital safety standards, patients and caregivers are increasingly becoming engaged in the design process.  However, not every organization understands how to engage patients in a purposeful way. Frequently patient participation never moves beyond a tokenistic consultation or a tick box exercise. So it’s up to us as patients and caregivers to lead the way and show the healthcare industry what meaningful engagement really looks like.

In my talk, I presented a roadmap to guide developers towards a worthwhile way to engage patients. A roadmap can be equally relevant to you as a patient advocate to guide your participation in the co-design process. Each of the following six principles reflect the value of patients as experts with rich insights and experience. Never underestimate the expertise you bring to healthcare and don’t allow others to minimize your contribution. Lived experience is equal to other forms of knowledge, evidence, and expertise.  Clinicians may be experts in disease, developers in technology, but you are the expert in your own life. You know better than anyone what it takes to live with your condition every day and which challenges you face in managing your illness. Ultimately, it is your insights that will help build a better healthcare system or solution.

6 Principles of Patient Engagement – From the Patient Perspective

1. Engage Us in Ways That Are Personally Meaningful

In an article entitled, Who Gives Us the Right to “Empower” Patients? , the authors point out that the health care system “continues to focus on engaging patients in behaviors that are deemed desirable from a mainly biomedical perspective: taking medications as prescribed, or maintaining a BMI below 25, for example. These desirable behaviors are considered universal, and it is assumed that all patients should engage in them to be optimally healthy. No space is left for individual patient goals, needs, desires, abilities, backgrounds, and other factors that make humans, and humanity, so rich and diverse.”

You cannot design health care solutions or services without taking into account patient values and preferences and the context in which we live our lives. Healthcare is complex; it’s connected to a lot of things which have nothing to do with technology. A failure to recognise the complexity of health systems and the reality of patients’ lives will continue to lead to short-sighted health initiatives.

2. Engage Us Where We Are – Not Where You Wish We Were

The most successful health applications are those that understand the real-life problems that come with living with a condition and creates solutions that meet real life needs. If an application does not solve a problem for the patient, it will not be adopted. As Amy Tenderich, founder of Diabetes Mine has said, “we will use tools that answer our questions and solve our problems. We will avoid tools that help us do what you think we should do and we won’t use tools that add to the work of caring for ourselves.”

Alex Butler, in an article entitled How To Build Successful Mobile Health Applications, wrote, “The question is not, ‘Does it solve a problem for the developer, or even the patient’s clinician?’ The real question is, ‘Does it help the patient directly? ’  If an application is in any way a hindrance, or adds any further time to the investment people must make into their healthcare, it will not be used.”

3. Engage Us Early in the Design Process

A report by Accenture revealed that just two percent of patients at hospitals are using proprietary health apps provided for them. This staggeringly low figure represents an alarming waste of resources. Accenture concluded that hospital apps are failing to engage patients by not aligning their functionality with what patients actually need. For example, only 11 percent of the apps surveyed offer at least one of three functions most desired by patients: access to medical records; the ability to book, change and cancel appointments; and the ability to request prescription refills. If those hospital app developers had worked with patients from the earliest design stages, they would be much more likely to produce an end product that patients would actually want to use.  “Co-design,” in the words of Renza Scibilia in her recent post Co-designing Co-design, does not mean showing a finished product to someone and asking for ‘feedback.’” It’s about involving patients right from the start of the design process.

Similarly, when it comes to research, it’s important that patients frame the research question. Historically, researchers have framed questions which are not particularly relevant to patients. As an example, the research priorities of patients with osteoarthritis of the knee and the clinicians looking after them, were shown in a study to favor more rigorous evaluation of physiotherapy and surgery, and assessment of educational and coping strategies. Only 9% of patients wanted more research on drugs, yet over 80% of randomized controlled trials in patients with osteoarthritis of the knee were drug evaluations.

4. Engage Us in Progress Reports

Genuine engagement is about shifting the traditional paradigm of patients as passive participants, to one in which we are fully involved as contributors who have a sense of ownership in outcomes. However, I’ve lost count of the number of times I’ve been involved as a patient advisor on a research proposal or steering committee and received no updates on its progress.  In her brilliant post, Patient Engagement: You’re Doing it Wrong, Isabel Jordan captures the feeling of being used which many of us feel in this situation. “I traded my family’s story for what, exactly?” she asks, “I don’t know, because I was never informed. Engaging patients means keeping us informed of the results of engagement. What happened to me is harmful. It took me from my home, away from my family, put me in a place of vulnerability, and put me in a place where I wasn’t respected.”

Sue Robbins, another vocal advocate of meaningful engagement agrees, and asks the question “how is it that patients and families are used for their stories and then crudely discarded? Why has even the common courtesy of responding to emails gone?”

5. Engage Us as Equal Partners

I also believe that valuing patients as equal partners extends to paying them for their time and expertise. Not everyone agrees with this position. But if those round the table are being paid, why not the patient who is also sharing their time and expertise? As Annette McKinnon, a founding member of the Patient Advisors Network (PAN), puts it, “patients can work as hard as anyone else in the health professions, and yet they are the only ones at the table with no badge, and who are not being rewarded for their efforts?”

Tessa Richards, writing in the BMJ, puts forward arguments both for and against payment. Whether or not to pay a patient is contextual, however, she is clear that “in a consultation where other experts are being paid for their time, patients and patient advocates should be too, and this should be standardized. My time and experience are as valuable as any other person at the table who is getting paid for being there. It amazes me how often patients are just expected to be thankful to be invited.” To quote melanoma patient advocate, Kay Curtin, “This is a re-shaping in many ways of what are the defined roles in research. We are talking about the patients knowledge and experience being of equal status to that of all the other interested parties on what research grant money should be spent on.”

(Note: The Change Foundation in Canada has developed a useful decision tool to guide organizations on whether to pay “patient engagement participants.”)

6. Engage Us Beyond Our Stories

Jordan is unequivocal when she says, “stop engaging patients if you’re not actually ready to partner with them.  Stop using our stories to get money for your research and your clinical programs. Our stories belong to us. If you’re going to use me, then I’d better be making decisions with you.”

Engaging with us starts with our stories, but it shouldn’t end with our stories. We are so much more than just “the patient story.” Dig beneath the story and you will find that a patient isn’t a disease with a body attached, but a life into which a disease has intruded. Our stories are not pawns to be used and then discarded.  Respect and value them for being, in the words of David Gilbert, Patient Director @SussexMSK, precious ‘jewels from the caves of suffering.’

(Note: PAN provides some excellent tips on its website, for patients and caregivers who are asked to share their story or experiences. It includes the advice to decline to share your story if you are not emotionally ready to do so.)

Final Thoughts:  Be Prepared To Say No

In a thought-provoking and wonderfully—articulated post on the nature of meaningful patient involvement in pediatric neurodisability research, Jennifer Johannesen suggests that “if there is insufficient effort to justify and substantiate what is being asked of you, or it’s unclear as to why you’re involved, you can decline.”  I am in full agreement with Johannesen and find myself increasingly turning down requests to participate in projects these days on this basis.

I firmly believe that a shift away from the rhetoric of patient engagement towards a genuine model of partnership, needs to come from the ground-up. We as patients have to be, in Johannesen’s words the “conscience, and the critical voice.” We need to challenge patient tokenism and push for real outcomes. We need to spur organizations to design solutions that not only work technically, but make a real difference in the lives of patients.   Only then can we hope to see the true meaning of patient engagement become a reality. To steal a line from David Gilbert, “nobody is going to take us seriously if we don’t.”

 

Clinical Trial MythBusters: Actionable Advice for Knocking Down Obstacles to Trial Participation

Actionable Advice for Knocking Down Obstacles to Trial Participation

Downloadable Program Guide

Clinical trials offer tomorrow’s medicine today, but more often than not, only a small fraction of patients ultimately enroll in a trial due to barriers posed by financial logistics, distrust and travel, to name a few. In this MythBusters program, we will examine the barriers to enrollment, evaluate patient needs and discuss resources to help guide people through the clinical trial process with the help from two experts, Dana Dornsife of Lazarex Foundation and Myeloma Survivor Reina Weiner.


Transcript:

Andrew: Hello from Carlsbad, California, near San Diego. I’m Andrew Schorr from Patient Power. Welcome to today’s Patient Empowerment Network program, clinical trials myth busters and actionable advice, resources for knocking down obstacles to trial participation. I wanna thank the companies that have provided financial support for this program. They have no editorial control, but we definitely thank them for their support. Those supporters are AbbVie Incorporated, Astellas, Celgene Corporation, and Novartis.

Okay. We have a lot to talk about. First of all, I’ll just say I’ve been in two clinical trials; one Phase 2 many years ago at MD Anderson for the leukemia I have, chronic lymphocytic leukemia. And that gave me tomorrow’s medicine today. It worked, but I had travel far to do it and there were costs involved.

And then I was in a second Phase 3 trial close to home, and that was good too, and discovered another cancer that I have, myelofibrosis, through the monitoring in the trial. So, I’m a believer, but there are obstacles, and let’s talk about some of these. And we’re gonna give you some very specific resources to overcome these obstacles, so that hopefully, if a clinical trial is right for you, you can participate, you can feel good about it, and you can move medical science along to help everyone who is dealing with that condition.

So, what are some of the issues? Financial, of course; logistical issues, of course; distrust, are they really gonna take care of you or are they gonna protect your safety? Is it really right? And are you being given the straight scoop? What about travel costs? I went from Seattle to Houston, Texas a few times. Costly, okay? Stay in a hotel. It’s costly. Get a babysitter, leave work; costly.

The guinea pig syndrome; you’ve heard about it so many times. Are they gonna experiment on you, and are they really protecting you, and are you a number, or you are a person with cancer, or your loved one? And then is your medical team that you’re talking to about your treatment, are they informed about clinical trials? Or are they pooh-poohing clinical trials because they don’t wanna do the paperwork, or it’s happening down the road and not at their clinic. Lots of issues; we’ll talk about that.

Okay, I got some great helpers. So, first let’s go to Asheville, North Carolina, and you are used to live in Charlotte. Reina Weiner joins us. Reina, welcome to our program today. There we go. Say that again, Reina, you were muted.

Reina: Thank you.

Andrew: Okay. Now we should tell you that last June, well, June of 2017, Reina had a autologous transplant for multiple myeloma. And along the way, leading up to that, over many years she was in four trials. So, first of all, Reina, let’s start with what’s most important. Post-transplant, how are you feeling today?

Reina: I’m feeling very well. Thank you, Andrew.

Andrew: Okay, and what’s coming up at the beginning of September?

Reina: What is coming up at the – oh, a big party is coming up. Our children are throwing us our 50th wedding anniversary party, so that’s been cool.

Andrew: Yeah. Well, congratulations. And you’ve been dealing with what became multiple myeloma since 1999. We’re gonna come back and track that in a minute, as far as the steps along the way, the concerns you had or not at different times about being in four clinical trials.

And now let’s go up near San Francisco in the East Bay of San Francisco Bay, Danville, California. Dana Dornsife. And Dana is the Chairman of the Lazarex Cancer Foundation. Dana, thank you so much for being with us.

Dana: Thank you, Andrew.

Andrew: Okay. Now ladies and gentlemen, I want you to know Dana and her husband and her family, overall, they’re incredibly philanthropic across a number of issues that are faced globally, and also in the US. But one of them is helping people with the financial issues that prevent them from being a clinical trial. So, Dana, this is a personal story for you, so maybe you could just tell us why did you start the foundation? It was a family issue.

Dana: It was a family issue, and that family issue really revealed to me a gap that exists in cancer care for advanced-stage patients who want to remain in their battle with cancer through clinical trial participation. My youngest sister’s husband, Mike, was diagnosed with pancreatic cancer in his early 40s. He was given one half of one percent chance to live, and at the time 35,000 people a year were diagnosed, and 35,000 people a year were dying from pancreatic cancer.

So, we decided as a family that if Mike wanted different results that we would need to do something different. And Mike and Erin went ahead and pursued standard of care, and I was tasked with identifying clinical trial opportunities for Mike. And, of course, that sounds very linear, but in fact, for a layperson it was a very difficult task to undertake. I did identify some trial opportunities for Mike. He did participate in a trial and responded well for a period of time, he had good quality of life.

And during that period of time he was meeting people who were asking him, “Hey, what are you doing? I wanna do what you’re doing.” And he would say to them, “Oh, just call my sister-in-law, Dana. She’ll help you.” And that’s literally how this organization began. Through those phone calls that I was receiving from other pancreatic cancer patients, I began to understand that Mike was able to take advantage of medical breakthroughs in clinical trials because he had a family who could afford to support him through the process. And all of these other families that I was talking to, they just didn’t have the financial wherewithal.

So, we started Lazarex in order to fill that gap and help people identify clinical trial opportunities, and then provide financial assistance to them to help cover the out-of-pocket expenses that create huge barriers for patients who are already experiencing financial toxicity due to their disease.

Andrew: Well, thank you for what you do. And we’re gonna talk a lot along the way about resources. There’s a downloadable guide that you’ll be provided with, along with a link to the replay of this program. And that’s gonna have specific resources that you can access, whether it’s financial issues, other issues you may be facing. So, look for that.

Today we’re really focused on actionable resources. So, let’s go to Reina for second. So, Reina, you had been in the pharmaceutical industry.

Reina: Yes, I had.

Andrew: So, you knew about drug development, and you understood about clinical trials. So, I’m willing to bet you were pretty proactive. People who weren’t in the field, they don’t know from clinical trials, and maybe they’d been worried about it. They’ve worried would they be experimented on, would they be a number and not name, would they get quality care. But you were probably, I have a feeling, pretty proactive. And you write about that. I know you have a book as well. So, is that Step 1 for people to speak up for themselves?

Reina: It is Step 1; absolutely, Step 1. And what I found is, first of all, people don’t know about trials. And if you go to a small community practice where they’re very busy, they don’t have the time, they don’t have the staff to really educate patients about trials, the best, best step for patients to take is to ask, “Is there a clinical trial that might be appropriate for me?” That’s huge.

Even when I went to a very well respected hospital and there was a researcher who was following me as I had smoldering myeloma and the numbers kept going up and up and up. I said is there – because I was living close to the NCI – is there a trial that would be appropriate to me at the NCI. And he said just a minute, turned around, went to his computer, found the trial and that’s how I got in.

Andrew: But it wasn’t at where you were receiving care or being monitored at that time. It was somewhere else.

Reina: It was not. It was at somewhere else.

Andrew: Okay. Dana, is one of the obstacles, not just financial, or maybe it’s even the business of cancer where if an oncology practice that you’re going to that’s maybe close to home is not doing the trial, maybe it’s not even in their financial interests to tell you. I mean, is there an awareness issue, do you feel?

Dana: There’s a huge awareness issue there, Andrew. And it all starts with knowledge is power, right, so I completely agreement with Reina’s comment about one of the first questions you need to ask is, is there a clinical trial out there for me because many doctors who are in community environments don’t offer that information. It’s not what they do every day. They’re there to administer standard of care. Only 6 percent of doctors actually engage in conversation with their patients about clinical trials, and that’s usually the 6 percent who are associated with research universities, right?

So, knowledge is power. If the patient doesn’t know about a clinical trial, they’re never going to participate. But once you find out and once you’ve identified an opportunity, the second biggest hurdle is that out-of-pocket expenses associated because most patients have been dealing with their disease for a longer period of time, and they’re basically broken in every way: physically, emotionally, spiritually, and, sadly, financially.

So, patients start to make decisions about the outcome of their care based on the size of their checkbook, and not focused on what’s best for them. And so, Lazarex eliminates that financial barrier as well to help patients say, “Yes, I can participate,” and we can get them where they need to be when they need to be there.

And that’s just the tip of the iceberg, Andrew, because there are many other barriers that exist; socioeconomic barriers, language, culture, historical barriers. And we are tackling all of those barriers one at a time. But really, the biggest two barriers are knowledge and financial.

Andrew: Right. And you mentioned about the historical barriers. Some people know about the Tuskegee experiments with African-American people, so in the African-American community, there still is a distrust among some people. Yet if you think about it from the FDA’s point of view where a company that’s developing a drug, or the NIH, they say okay, how does it work on broader populations or different ethnic groups or different ages or genders, et cetera?

They want to understand that data, and so not just having a number of people participating in the trial, but having it reach people who are in different situations, if you will. And so –

Reina: And if I may – ooh, I’m sorry.

Andrew: Reina, please, go ahead.

Reina: Well, if I may say that because people don’t know about it and the trials, the best trials, are trials with a variety of patients, but they do try to accrue populations who are certain ages, certain genders, ethnic groups, whatever they can get. And only 3 to 5 percent of patients participate, cancer patients, participate in clinical trials, and so much is lost if people don’t participate.

Andrew: Here in San Diego it’s sort of a pocket of a lot of medical research. There’s a lot up in your area, Dana, in the Bay Area, San Francisco Bay Area. I mean, it’s in North Carolina in the research triangle where that’s home state for Reina. And not to disclude others, and then certainly up around Boston. There are like companies all over the place and many of them are in earlier drug developments.

So, when you talk about immuno-oncology now, can we harness our immune system with the help of some medicine to fight the cancer, and I know some people who’ve received it; lung cancer patients who are living, et cetera, melanoma patients who are living for an extended time. These companies can’t move forward unless there’re people who are in the trials. So, the FDA says where’s your data? And they’re saying well, we’re trying, but we haven’t been able to complete this trial. Right, Dana? So, we can’t move towards cures unless we all come together.

Dana: That’s exactly right. So, let me just throw a few statistics out at you that I found astounding when I learned of them. So, we have a 48 percent failure rate of clinical trials, and it’s not because the drug didn’t work. We will never know, quite frankly, if the drug would have worked or not. And we will never know because there weren’t enough patients enrolled in the trials to find out.

So, 11 percent of trials never enroll a single patient, if you can believe that. So, here we are with an almost 50 percent failure rate, and yet we have 600,000 patients a year in this country who are dying from cancer. So, there’s this incredible disconnect between the thousands of patients who would participate in clinical trials if they could, and the thousands of clinical trials that need patients to participate in order to succeed. And without successfully completing those trials, those drugs are never going to get market to help the cancer patients that they are intended to serve and help.

That’s why Lazarex Cancer Foundation exists, and that’s why removing the barriers to clinical trials is so important. Our process does not lend itself well to that. And I just want to take a step back, Andrew, to address the minority participation in clinical trials. We all understand because of epigenetics and, yeah, advances in medical science that we need to have the full spectrum of our population participating in clinical trials. But that doesn’t happen. When you look at the 5 percent of patients who actually participate and you break it down ethnically and racially, less than 5 percent are from minority communities combined.

So, in theory, though we say we understand the importance of that, we’re actually not in practice doing what needs to be done. And so a lot of our work is also focused on reaching out to those socioeconomically challenged and racial and ethnic minority communities to raise awareness and help people like you’re doing on this program dispel the myths around clinical trials, so that they’re more inclined to ask better questions.

Andrew: Right. So, so important, and I applaud for that work. We’re gonna talk about the financial process in a second. Reina, so you were involved in a National Institutes of Health or National Cancer Institute trial.

Reina: Yes.

Andrew: A couple of them, I think, and one at Memorial Sloan Kettering in New York’s premier resources. So, we talked about your tip was you gotta speak up and ask about trials, where they’re at that center, wherever you are, by XYZ oncology in a suburban area, whatever it is or not. So, what’s Step 2? So, for instance, now I understand there are people – and Dana, I’d like your comment on it too.

At some clinics now where there are clinical trial – there are nurse navigators, but often sometimes there are clinical trial navigators too, but often you gotta ask about that too, right, Reina? I mean, it’s speaking up and looking for the resources that are available to you there or wherever you choose to go, right?

Dana: Yes, and there are organizations like Dana’s who help people do clinical trial searches because that’s a bit overwhelming when you are already frightened, you already have the financial issues coming up. And like you mentioned, logistical issues. So, there is Dana’s organization; therefore, myeloma, the SparkCures. There’s the MMRF. There’s the International Myeloma Foundation. There is something called Cis Crypt. And so, they will help you find a trial.

And there are lots of regional trials groups, so you may not need to go to the big, big research center. They might be able to do it locally for you. But I always want to bring up the fact that there’s so much misinformation about trials and what it entails. There’s a tremendous amount of fear. And when I went on the first trial, as I wrote about a little blog recently, everybody said to my husband – well, not everybody, but an awful lot of people said why would you let your wife going in a clinical trial? She’s definitely gonna be a guinea pig.

And I can tell you very, very, very clearly that you get so much care. There’s so much documentation. And the patient’s health is never sacrificed for the research ever. And so, and you sign a consent form, so you’re very clear about what is going to happen. And yes, there’s more there’s more bloodwork. Yes, there are more biopsies. And it’s part of research. And when you sign up, you sign up. And I had more than I’d like to even talk about, but I feel very grateful and very humbled for the care that I received.

And I can tell you, too, that I talked to other people on the trial. And yes, they hope to gain better control of their cancer. But, in addition, they really hope to help the next group of patients who are coming up, so that these new treatments actually happen.

Andrew: I feel the same way. I was in a trial at MD Anderson in 2000, and the three-drug combination I got was not approved till ten years later, but they learned a lot. And you were on a three-drug combination, which I think still has not been approved for first line, but it’s is widely used, I think.

Dana: Right.

Andrew: So, in multiple myeloma. I wanted to mention some other resources, the Leukemia & Lymphoma Society also has a resource center. You can call them. So, there’re these different groups that help you identify a trial, and doctors who specialize, so let’s say pancreatic cancer, you mentioned earlier Dana. I got a call from a friend in Miami, “How do I find a pancreatic cancer specialist?” And I connected them with PanCAN, Pancreatic Cancer Action Network in Los Angeles, who knows who are the doctors who have the most experience with that.

Now, Dana, so then the next thing comes up is alright, I’ve identified the trial, but it’s not where I am. So, now we talk about logistics and finance. So, let’s say somebody calls your foundation. Tell us how it works. So, I don’t have the resources. Maybe they live in Northern California and the trial is in Southern California or in Salt Lake City. What happens next?

Dana: So, Andrew, in some cases it’s not even that distance. In some cases it’s getting from Sacramento to San Francisco, which is literally a one hour, one-and-a-half hours without traffic, in your car. And sometimes it’s a tank of gas, a bridge toll, and parking. I mean, we’re not talking about thousands of dollars in some cases, but it’s still the difference between life and death.

When someone calls Lazarex Cancer Foundation, they can contact us directly. We have a financial application that we use to determine the degree of eligibility for patients to get their out-of-pocket expenses reimbursed. Or they can be referred to us by their social worker at the institution where they are receiving, or thinking about participating in a clinical trial.

We take a look at the household income of the patient, and I believe our guidelines are very generous. We go up to seven times the federal poverty guidelines for patients. And we arrived at that number through trial and error. Our goal is to help as many patients as possible participate in clinical trials, and turn away as few as possible. And then we reimburse on a sliding scale from 100 percent to 75 percent to 50 percent depending upon your household income.

And it’s a pretty easy process to go through in order to be enrolled and receive the reimbursement. And then we reimburse our patients monthly, on a monthly basis. And in some cases, we’ve been working with patients, we follow them, like Reina, through two, three, four clinical trials. And we’ve been supporting them in trials for years. And without doing what we do, they may not be here with us today.

Andrew: Well, I’m sure you’ve saved some lives and lengthened some lives. Reina, so you were in the pharmaceutical industry and in oncology, I believe, before all of this started happening to you. And you’ve continued teaching nurses and devoting yourself to education and your book and your blogs. Thank you for all that. Maybe that’s what life’s about.

But knowing on the inside there are pharmaceutical programs, in some cases, I think, particularly for rare cancers where they may provide assistance. They can’t pay you to be in the trial, but there are at times assistance and travel logistics, particularly for rare cancers where maybe the trial is not, not one hour away. Am I right, Reina? Are you familiar?

Reina: Oh, there are. And sometimes when I was working, there would be a patient who had a cancer that really was not aligned with a particular treatment that would be effective for them. And so, the doctor wanted to try an off-label use of a product, and so then they would come to me and asked me if I could get the pharmaceutical company to provide the drug for free.

And sometimes it takes a little doing, but I was concerned about the patient and hoping to get them a better quality of life, if not an extended period of life. And so, yeah, the company would do that. Not every day, not all the time, but if the company had evidence that this was a patient who would benefit from the off-label use of a product then they would help them out.

Andrew: Okay. So, Dana, related to other organizations providing assistance, and I recently interviewed someone from the Family Reach Foundation where they help with rent or things, groceries, things like that. So, somebody says, “Oh my God, I’m afraid of a trial, I can’t go there,” or if they hear about it and they say, “Hmm, well, maybe I could, but I’d have to leave work, or maybe my spouse would have to leave work, we’d have to find somebody to pick up the kids from school, oh my God.” There are organizations that can help with some of these family processes, aren’t there?

Dana: Absolutely. And I think we’ve provided the Patient Empowerment Network with a list of those. 21st Century C.A.R.E. is an organization that provides patients with immediate financial assistance for expenses related to active cancer treatments. Cancer Care provides assistance for cancer-related costs. There’s a Cancer Care Co-Payment Assistance Foundation. We get that question a lot.

We’ll help with the out-of-pocket travel expenses, and in fact, some of the medical and diagnostic expenses that aren’t covered by insurance. When you’re participating in a trial, sometimes you have to get more stems than insurance will cover or whatever. But co-pays are a big deal for people to be able to afford those, and so, that is another organization that can help. Patient Advocate Foundation, which is an underinsured resource directory.

So, there are a lot of you nonprofits out there who exist to support patients through the fifth process. It’s just a matter of helping patients really understand and put together all of those resources in a way that they can access them.

Andrew: Okay. So, Reina, you’ve been through it four times, and you’re a pretty savvy person. Not all of us know as much, so help us now. So, one of the questions in a trial is, and in cancer, am I gonna get what I describe as the good stuff, knowing that the good stuff that’s being tried may not be good. I mean, it may not work out. There are trials that go bust. Not just for not getting people, but they got people, but it wasn’t as effective as they hoped it would be.

But let’s say we’ve done our homework and we go to a certain clinic, but it’s some sorta controlled trial. We don’t know whether we’ll be in the arm. So, was a concern for you? Were you gonna get the good stuff, and why do it?

Reina: Well, no, really, Andrew, because I know that like if it’s a Phase 3 trial, so you’re comparing standard of care versus the newest and hopefully the latest and greatest. If it turns out that one arm of the trial really shows a significant improvement, patients are always switched to the more effective arm of the trial. They don’t leave you on this arm of the trial thinking well, what the heck, we’ll just leave you there and see how the research pans out. So, they are always switched over to the most effective.

So, I wasn’t really concerned about that. And in the Phase 2 trial, it’s just seeing if the product was effective. And so, that was obviously not a concern for me. So, it worked out, and I do think, though, like what Dana does is absolutely wonderful at totally, totally, totally past wonderful.

But I always try to let people know who have friends and family who are facing some chronic significant illness that don’t just call and say let me know, let me know if I can help you because that’s so ambiguous. And most people will not call because they have pride or they think they can do it all by themselves.

So, I always try to suggest to people that if you’re calling somebody who you think might need some help, be specific. Call and say, “Can I walk the dog? I’m going to the grocery store in an hour. Is there something I can pick up for you? Can I mow the grass?” Anything that will help, but make sure that you are specific in your offering.

Andrew: I want to talk about a related issue. You use the word pride. Some people, maybe in some cases it’s even shame. They developed a certain cancer. Where these are maybe middle-class people who’ve had some resources. They’ve been paying their mortgage. They’ve been paying their expenses, making do. But now they get hit with a cancer diagnosis, which is catastrophic, and there is help available, Dana, but they’re too proud to ask for it when this could happen to anybody. And maybe you’ve even countered that along the way or know there’re people out there. What would you say to people, to not be shamed and to speak up?

Dana: Yeah. Well, sadly, one in three women will be diagnosed with cancer, and one in two men. And so, this is not an uncommon scenario, right? The likelihood of knowing someone who will receive a cancer diagnosis is very likely. So, I think that patients have to understand that pride doesn’t help you in your process with battling this disease. You have to take advantage of every opportunity that’s out there in order to come out on the positive side of this experience. And if you don’t take advantage of every opportunity, you may not.

And so, it’s one of those things that we just have to deal with right from the beginning, and just say okay, again, knowledge is power. I’m going to surround myself or engage with the people that are around me who want to help me. And you have to put that team together because you will need your team with this disease.

Andrew: Okay, so great advice. Reina, part of your team maybe could be the first doctor you saw who gave you the diagnosis, but they might not be the one where a trial was offered. So, first step is you talked about speaking up, but it takes a lot of courage to say to the doctor in the white coat with all the letters after their name, you know, thank you so much, Doctor, and I’ve either found out about a trial, or your turned and typed it in somewhere else. I hope you don’t mind, but I am going to go over there. Maybe you can advise me along the way.

But that takes courage because people are terrified, and they may be bold in principal in that situation with the person in the white coat. What advice would you give?

Reina: Ooh, well, that’s a big one for a lot of people. And, really, you know what, I imagined that it would be people who are older, who come from a generation where the doctor has the final word. But what I found out when I was writing my third book is that there were younger people who also feel very uncomfortable speaking up, asking a doctor, and so forth. But really, what to really put in your little mind and in your heart is this your life.

This is not just kind of a trip to the mall. This is really important for you to either improve the quality of your life or extend the quality of life, so take a deep breath, be very polite, and I think most doctors who are professional and open-minded will hear what you have to say if you present it in a way that they can hear. And if they really don’t hear you then it might be time to have a look around to see who will.

And, really, the bottom line is you need to trust yourself. And if you feel that this is really right, that there is a clinical trial that you would be eligible for and you can participate in with Dana’s help, with the financial, with the logistics, and so forth. Like I said, you just take a deep breath. And most doctors, like I said, really want the best for you.

Andrew: Okay, let’s talk about something that comes up. One of the things for people is the criteria of different trials. Dana, I don’t know if this is in your area, too, related to financial, but people let’s say okay, I wanna be in a trial, but the criteria are so narrow that I really wanna be in the trial, but they say I can’t.

Dana: Yeah, so that is a sad reality in many cases. And I refer to this as Clinical Trial Nirvana Syndrome where as a drug sponsor for trial, you want to attract the healthiest patients you can to participate in your trial, so that you have the greatest chance of success. But, unfortunately, in many instances, in most instances, a cancer diagnosis is accompanied by other comorbidities like heart disease or diabetes or other maladies that would preclude a patient from being able to participate in a trial.

So, that is an area that we are looking into and trying to – we have several proposals out there with various aspects of our government to try and really take a closer look at that, to try and make the trial makeup in relation to patient participants better mirror the realities of our situation because the likelihood of someone, if the drug gets approved, taking that drug and having a comorbidity is pretty likely.

And yet we won’t know what will happen there, right. So, we have to drill down on these issues and it’s a great, great issue to bring up. So, we’ve got a lot of work to do ahead of us.

Andrew: Right. And another thing that comes up too, and Kevin sent in a question. Kevin, thank you for this, matching what’s available in clinical trials to where you are in your journey with an illness. So, on Day 1 you’re diagnosed. I know Esther and I, we were crying and almost on the floor. And I thought I would be dead the next day. And it really took a while to overcome the terror of the diagnosis. And so, we were not even – well, the doctor wasn’t talking about trials; we wouldn’t have been hearing it anyway.

And some of us, thank God, with some trials, with some cancers now, are blessed with living longer and we start to learn. And then we want to know, in our situation, what applies to us. So, I know there are a lot of efforts being made to match trial offerings to where you are and what you might need to know now, what might need to be offering.

And some of you have heard this term, artificial intelligence, where we in the Internet business are all trying to fine tune what we’re suggesting or putting in front of you based on who you are and where you are, recognizing privacy and all those kinda things to make it more manageable.

We still have a long way to go. I mean, we have clinicaltrials.gov, but it’s not tied to where I am, who I am, where I am in my journey. It’s just what’s being done in a certain illness, right, Reina?

Reina: Yes.

Andrew: So, we have to refine our tools.

Reina: Absolutely.

Andrew: We have to refine our tools. Well, we’ve been getting in a number of questions. So, here’s one. So, David; so, he says as the excessive use of CT scans in clinical practice moves away from being the norm, have they lessened their use in clinical trials? In other words, this is about testing, and maybe it’s about the requirements.

Dana, I don’t know if you have feelings about it, but the scientists who are doing these trials, they wanna know everything. They would like to test us. So, the CT scan, and I mean I’m gonna have one next week, but it has radiation, right?

Dana: Right.

Andrew: So, let’s do a bunch of CT scans. No, let’s do a bunch of bone marrow biopsies. No. So, I’m saying I’m sorry. Not just do I have to pay something for these tests, or is there a co-pay or whatever, but also am I gonna be radiated? Am I gonna be poked? So, what about those issues? Is there dialogue going on, not just to help us financially, but also make it less onerous, I guess?

Dana: Yes, in fact there is dialogue going on about that, and it’s good, heartfelt dialogue. And it’s coming from a myriad of stakeholders, right, not just from patient advocacy organizations, but also from within industry insurers. And the whole goal is to okay, let’s stop looking at patients as a chart or a number on a piece of paper, and let’s understand that these are living, breathing human beings who are voluntarily participating in this clinical trial process for the benefit of not only themselves, but future patients to come and our industry.

And let’s start treating patients as humans who are participating, and let’s see what we can do to lessen the number of visits or minimize the number of scans and blood work, et cetera. So, there is active dialogue around that, and I think there’s a much higher degree of sensitivity on behalf of the teams who are actually putting the protocols together now.

Andrew: All right, I think so. And I know in some cases they’re doing what’s called trial simulations with a panel of patients and saying okay, we’re trying to answer these scientific questions and see if this drug that’s in development can do better for patients and would require so many office visits. Or so many, you come to the site, but so many could be done, maybe with your local doctor if that’s closer to home. So many blood tests, so many CT scans, so many biopsies. Imagine lung cancer patients with another lung biopsy. Not fun, and often not available.

So, there are all these kind of questions. And I think that’s going on although it needs to happen more. Now Dana, do you talk to the pharmaceutical industry? We had a question from Vi Life wanting to know related to trial awareness. Beyond the financial, do you work with pharmaceutical companies at all, as you are now, today? I mean, what we’re doing here is just to raise awareness about trials or other programs that you may do.

Dana: So, we are engaging with pharma right now. We were very fortunate to work with the FDA earlier this year in securing language around reimbursement of patients’ out-of-pocket expenses associated with clinical trials. There was some very nebulous language out there that was really preventing pharma from being able to support programs like ours.

And what we’re doing now is, in addition to we’re bridging this gap for patients that exist every day by reimbursing patients, but that is not a sustainable business model. It’s noble, but we have to have our tin cup out every day. And the number of patients we can help is directly related to the amount of money that we have in our account, right?

So, in addition to that program, our Lazarex Care Program, what we are also doing is trying to fix this problem and do it in a sustainable way. And in order to do that, we actually have to shift the burden from the patient back into industry, right, and help industry understand why they should include these out-of-pocket expenses as part of the clinical trial protocol every time, right, so they can enroll trials on time, on budget, save R&D dollars, preserve patent years, right?

I mean, there are a lot of reasons why pharma would want to participate in a program like that, in addition to the fact that it’s the right thing to do, right? And then we get more drugs to market faster, and we provide a platform of equitable access for everyone. So, we are engaging pharma in discussions right now about funding this program, we call Lazarex our IMPACT Program, that’s being rolled out at comprehensive cancer centers across the country. And it stands for Improving Patient Access to Cancer Clinical Trials.

It has been received very well and I’m happy to say that Amgen actually stepped up and funded this, so we are rolling it out here in California, and we are hoping that we’ll have similar opportunities in a couple of other areas in the United States. So, they are interested, and they want to improve clinical trial enrollment retention, and especially minority participation.

Andrew: Right. Boy, that you. Again, I keep saying thank you for what you’re doing, but you’re a real leader in the field. I’m going back next month to the Biden Cancer Initiative Summit continued by Vice President, Biden, former Vice President Biden, and his wife who continue to do leadership in this. And there’ll be a lot of senior people there and I’m hoping we can talk. And I know this issue of how can we advance cancer care through research in partnership with patients is a big one. So, Dana, thank you for helping lead the way in getting this going. And thanks to Amgen just as an example.

Reina, so, we talked about the cultural differences of people being in trials. We talked about the pride people may have in asking for assistance, the fear people have maybe participating in trials. You still have a – not now. I mean, you’re doing so well and you’ve been through trials and it’s worked out well. But there must have been some bumps along the way. Were there any misgivings at different times? And if so, how did you overcome it?

Reina: Oh, yeah. Well, there were definitely misgivings, I am sure. The first trial was when I asked the doctor if there’s something going on at the NCI. And there was no misgivings about that because that was a very observational trial. The second trial was much more progressive and I felt kind of a little uncertain about it, and so I asked the researcher at this well-known institution if I should participate because the trial, I should back up a little bit, that was for either smoldering myeloma patients or active disease patients.

At the time I was smoldering, and most physicians didn’t believe that that was a good idea to treat smoldering and wait until it became active. So, I asked this one researcher and he said absolutely, not, do not participate in the trial. And then I called someone else also from a very respected institution where I had been, and he said well, if you join that trial you’ll be crossing the Rubicon, which I didn’t even know what the Rubicon was at the time. I had to go look it up.

But, basically, once you start treatment, you kind of go on that journey and there’s no way to step off. But then I thought about it, I thought about it, thought about it, and finally I decided to trust myself because I had been to the NCI. I felt very safe there. And I decided to move ahead with it.

So, yes, I had plenty of misgivings about that. The other trials, not really because that trial changed my life and it gave me a very reasonable complete response. And the other ones, like I said, they just kinda fell in with the collecting a good amount of stem cells for a transplant and so forth.

Andrew: I wanna talk about family issues. So, the decision to be in a trial affects the family, whether it’s somebody’s driving you to the doctor, somebody’s taking off work, their worry, how they feel about trials, their own view of it, family logistics, costs, et cetera. We’ve talked about that. So, you wrote this blog about people questioning your husband, I guess, was your wife gonna be in a trial? So, how did you overcome that, whether if not with your husband, just with your community that you weren’t like crazy?

Reina: Well, they already know I’m crazy, so that’s a total aside. But, really, trying to educate people about the misinformation about trials; say, look, I will never be a guinea pig because that’s not what trials are about. And it’s very well controlled and there’s a lot of data that follows you. The care that I got was excellent.

And I try to dispel, like I said, a lot of the myths; that you signed consent form, which clearly explains what the trial is about, what your commitment to it is, and you can also drop out for any reason. There was hope that you don’t because they would like to have some results that then will lead into future treatments for patients. But you can drop out, so, really, taking that opportunity to educate people about what a clinical trial is like and that there are no guinea pigs.

Andrew: I wanna just – oh, yes, please, Dana.

Dana: Yeah, if I could just offer something in that regard. For people who haven’t gone down this path, the journey with cancer, having a cancer diagnosis is not like other chronic diseases, right, like diabetes, for instance, that you can typically control with insulin or whatever, right? For a cancer patient who has failed standard of care, who’s gone through maybe second- or third-line treatment options, but still has progressive disease, that patient will die if they don’t do something, right?

And so, clinical trials offer tomorrow cures today in some instances, right, and we don’t always have positive results in clinical trials. But for a patient who’s at that crossroad where their doctor has delivered those words, “You need to get your affairs in order,” right, it’s not a matter of am I crazy if I participate in a clinical trial. What it is a matter of is do I wanna live? And if so, what clinical trial can I participate in? It’s a very different decision tree.

Andrew: Right. And I certainly say that all the time. I got a call, as I mentioned, from a friend in Miami. The mother has a very serious cancer. And I said part of the initial discussion, even the initial discussion, Dana, can also be are there clinical trials that we should consider along with standard therapy? So, certainly, if you’ve failed or they’ve failed you, the treatments no longer work, what is the 360 degree view? And if you don’t do it here, so they do it down the road, or do they do it across the country? And what are the issues for you participating?

So, a lot of thinking, but it’s gotta be part of the discussion. So, so sadly now, what are we seeing; 3 percent, 4 percent, 5 percent of adults participating in cancer clinical trials in the US. Not good at all. And are we hurting ourselves with the chance of future therapies that can be more effective, or even cures because some of these companies sometimes are venture-backed. They don’t have money forever, you know, and they’re trying to get to the goal line to go the FDA.

Look, here is another question we got in. Tamara, our producer, just sent in. She says well, what happens when you join a clinical trial and it doesn’t have a beneficial impact? So, Reina, they didn’t know that the trials would necessarily work out for you. So, what happens then? Do you go on another trial? What do you do?

Reina: Well, if it doesn’t and you don’t seem to be responding to the therapy on the trial, or you find it intolerable yourself, then they will always return you to your oncologist who you had been seeing previously. But, on the other hand, they may offer you another trial that’s available that you would be eligible for as well. So, I mean, I really try to stress to people that the researchers are looking out for you. They want the best income, in addition to accruing the data that they hope.

And I can tell you that when I was on a trial at the National Cancer Institute, when I had questions, especially about the trial with smoldering versus active disease for myeloma, they would spend a couple of hours for me, explained with me, can I say that, right? Yes, spent a couple hours with me explaining all of the aspects of the trial, so yeah.

Andrew: I wanna point up an example that some people have heard of a woman I’ve become friendly with in the myeloma community, Reina. Cherie Rineker. So, Cherie’s down in Houston, and she was dying of myeloma. And she’d been in trials and treatments. She was at MD Anderson. Bob Orlowski is one of the top doctors in the world, and her doctor. And she was in different trials and then things were not working.

And she was put in touch with another researcher doing this CAR T investigation for multiple myeloma, which is pretty new, pretty new. And they’re learning a lot. It’s not a slam dunk, but so far it’s worked for her. It saved her life. She went to Nashville, Tennessee from Houston where she lives, and maybe I’m not sure the financial issues, Dana, about going. But that’s where she’d been in successive trials. And some were not working or no longer were working. There was another approach.

I wanna ask about another concept I’ve heard called siteless trials. And I don’t know, Dana, you’re nodding your head. Maybe you are familiar with this. One is a siteless trial because we talked about these trials going on at these academic medical centers, but not much elsewhere.

Dana: So, I have tell you, I don’t have a lot of experience with siteless trials, but there is a lot of dialogue taking place around rather than having the patient go to the trial, bringing the trial to the patient, and I think that’s the impetus behind a siteless clinical trial.

I think cancer has some unique challenges, especially blood-based cancers in clinical trials, and the oversight of patients participating in those trials that make siteless trials a bit of a challenge. But I think the place to start is in other diseases, or perhaps where you have a cancer diagnosis that’s not a rare form of cancer, whatever that requires, a high degree of oversight.

But the whole goal in doing this is to understand how we can get more people into these trials and make it less obtrusive on their life, right, so that more patients would be inclined to participate, increase our enrollment retention, our minority participation, and, ultimately, reduce the burden on the patient to participate.

Andrew: Esther and I’ve given a lot of talks at different conferences, and we said you have to see patients who might be considering or are in a trial as investors. So, they’re gonna invest with their body, their time, sacrifices, and other things in their lives for the hope of being cured if they could, or doing better.

And there needs to be the communication, financial support, logistical support in really treating people with a lot of respect as a person. Reina, do you agree with that, that we have to get to that concept where we’re taken care of? And you felt that way, but we need to do it for more people and have more people feel confident that it’ll work out that way.

Reina: Oh, certainly. Certainly, I do. And the education is really essential. And after I was in the first trial, I talked to everybody who would listen to me. And even if they didn’t, I would talk anyway just to try to say this is a place where you can go where you will receive what is hopefully the newest and the best treatment that’s available. That you will be cared for as well as you can possibly be, and that everything is documented. You know all the options that you have staying on the trial, giving consent, making sure you have all the information that you need to feel comfortable.

And Dana’s organization, hopefully, helping people out financially and logistically. There are ways to get into trials that at times are very successful. For me personally, I don’t know that I would be alive now if I had been on that trial, and that’s really my claim to fame, what can I say?

Andrew: And, Reina, I would say the same thing. Had I not been in a Phase 2 trial for chronic lymphocytic leukemia in 2000, I wouldn’t be around to have had retreatment last year, which has work quite well; 17-year remission. And I wouldn’t have been able to do this, and really have a purpose in life. So, I’m very grateful for being in the trial.

Dana, I can’t tell you – we were talking about gratitude, for you; came up in your family. You saw the gap for, not so much your family, but so many other families. The issues, financial issues, and you’ve been very philanthropic and, obviously, trying to have leadership in getting at some of these – we have a very imperfect system right now, so we have a long way to go. But for our viewers, if you’re living with cancer now, if your loved one is living with cancer, there are resources, people like Lazarex, people have been through it, like Reina.

We’re gonna give you this downloadable guide. And you’re gonna connect with these resources. Don’t… Put your pride away. Dana said it so well. There’s a very high likelihood we’re gonna be affected by cancer in our families, and there is help to navigate what’s kinda complicated right now, but is doable and can offer you the chance of doing better. Dana, did I say it right?

Dana: You did. You did. You did a great job, Andrew. Thanks.

Andrew: Okay. Well, thank you. And thanks to the Lazarex Cancer Foundation and, really, all you’re doing. And let’s hope that we can improve this process, increase participation, and have so many of these companies and the government that are trying to get scientific answers. We participate as respected patient investors. And we do better well. Reina, any final words from you with your 50th wedding anniversary coming up?

Reina: I’m very grateful. I’m very grateful to be here. I’m grateful for all the clinical trials, all the physicians who have taken care of me and who listened to all my concerns and fears. And I am super-duper grateful to my husband who has supported me, helped me, been there, been my caregiver, and washed the food for me when I had the transplant, and really, all the people who have been on the journey with me. So, if you are considering a clinical trial, if there is one that you might be eligible for, give it some thought. It’s a really important choice for you to make.

Andrew: Reina, thank you so much, all the best. Happy anniversary, early. Dana, best to you. Dana Dornsife, joining us from the Lazarex Cancer Foundation in the San Francisco Bay area. Dana, good health to your family, and thank you for all you do. Thanks for being with us, Dana.

Dana: Thank you.

Andrew: And, Reina, all the best, and thank you for those great words of wisdom. And we’ll meet in person sometime and I’ll give you a big hug, okay?

Reina: I hope so. I hope so. You take care of yourself, Andrew. Thank you so much.

Andrew: Thank you for joining us for this Patient Empowerment Network program Clinical Trials Mythbusters. We hope to do more. I wanna thank the companies that have helped provide funding for it; Abbvie Incorporated, Astellas, Celgene, and Novartis, for their support.

Thank you for joining us. I’m Andrew Schorr from Patient Power down near San Diego. Remember, knowledge can be the best medicine of all.

Reinventing the Clinical Trial: Start at Ground Level

If each of us humans is a snowflake, unique in our genomic makeup, where’s my snowflake medicine? I asked that question from the platform at the ePharma Summit in New York in 2013, and have yet to get an answer. The challenge for the bioscience industry is, I believe, the classic randomized clinical trial. That design goes through four phases:

  • Phase 1: a small group of people are given the drug under study evaluate its safety, determine a safe dosage range, and identify side effects
  • Phase 2: a larger group is given the drug to evaluate its efficacy and safety in a larger population
  • Phase 3: large groups – plural – of people are given the drug to confirm its effectiveness, monitor side effects, compare it to other commonly-used treatments, and collect information that will allow the drug /treatment to be used safely
  • Phase 4: the drug is marketed while study continues to assess long-term effects and efficacy

Of course, before they even get to Phase 1, there have to be both the idea for the new treatment, and animal studies to determine what the substance or compound under study might do to a mouse or a monkey.

Science isn’t easy. The phrase “trial and error” came out of science labs, with many trials running up against the error wall by Phase 2. Since bioscience companies can sink about $1 billion-with-a-B into getting just one drug to market, it seems that the traditional clinical trial has turned into a pathway to NOT making scientific discoveries that can benefit humankind.

Then there’s the whole “who’s in charge here?” question. Clinical trials are now a global effort, with US and European pharma companies testing new treatments in Latin America, Russia, and China to gain traction in those emerging markets while simultaneously developing me-too drugs for their domestic markets. So, who’s in charge, the US Food and Drug Administration (FDA)? The European Medicines Agency (EMEA)? A player to be named later? The answer to the question seems to be “all of the above,” which adds to the complexity of the clinical trial process.

As digital technology has made data easier to collect and share, it would seem that clinical trials would be a great place to start intersecting with the quantified-self movement. The shift to electronic health records, the widening adoption of all sorts of health tracking devices, and the rise of (relatively) cheap genomic sequencing should signal an ability to identify conditions, and populations, eager to participate in clinical investigations. But so far, it hasn’t.

What might challenge that stasis? In November 2013, three major pharma companies – Novartis, Pfizer, and Eli Lilly – announced via the White House’s website that they had joined together in a clinical open innovation effort. That page on the White House’s site is gone now – changes in Presidential administrations will do that – but here’s a direct quote from that announcement:

“In order to connect patients and researchers, Novartis, Pfizer and Eli Lilly and Company, are partnering in the U.S. to provide a new platform to improve access to information about clinical trials. The platform will enhance clinicaltrials.gov and will provide more detailed and patient-friendly information about the trials, including a machine readable ‘target health profile’ to improve the ability of healthcare software to match individual health profiles to applicable clinical trials. As part of the project, patients can search for trials using their own Blue Button data.”

Five years later, and we’re still stuck on the slow train when it comes to really reinventing the clinical trial.

I’m one of a growing group of people who think that the entire life-sciences process chain needs to be re-tooled for the 21st century. In my view, the best place to start that re-tool is at ground level, with the patients and clinicians who deal with challenging medical conditions daily. If a doctor has a number of patients who might benefit from some clinical study, why isn’t there an easy way to find a researcher looking into that condition? If a patient has an idea for a clinical investigation into his or her illness or condition, why can’t they find a researcher who’s interested in the same condition to team up and start a science project?

I can only hope that the regulatory agencies involved in life science oversight (hello, FDA!) can move beyond the aftermath of Thalidomide – for which epic disaster we’re still paying a price when it comes to the timeline for drug approval in the US – and toward a process of “all deliberate speed” that doesn’t forsake speed for deliberation. Both are necessary, neither should be more heavily weighted than the other.

We all can, and should, take part in scientific exploration into human life, and human health. Got an idea for a clinical trial? Share that idea in the patient communities you hang out in, and ask your tribe to help you bring that trial to life. To quote Arthur Ashe, “Start where you are. Use what you have. Do what you can.”

We’ve got to start somewhere, right?

Ask the MPN Expert – Dr. Naveen Pemmaraju

Ask the MPN Expert – Dr. Pemmaraju

“Ask the Expert” session with MPN specialist Dr. Naveen Pemmaraju from The University of Texas MD Anderson Cancer Center.


Transcript:

Andrew: And greetings from near San Diego, Carlsbad, California. I’m Andrew Schorr from Patient Power. Welcome to this patient empowerment network program, and thanks to Incyte Corporation for helping make it possible. They have no editorial control. I’m a myelofibrosis patient, have been for several years, so I’m vitally interested in this. Welcome to our MPN community, and welcome to one of our favorite experts joining us from MD Anderson Cancer Center in Houston. There’s Dr. Naveen Pemmaraju. You can see behind his desk there all the working on the cures of tomorrow, but Naveen, thank you so much for being with us.

Dr. Pemmaraju: Thanks for having me, Andrew. My pleasure.

Andrew: Okay. Let’s get right started. We’ve gotten all sorts of questions in. If you have a question, send it to MPN@patientpower.info, but we’ve gotten a lot already and I’ll start to buzz through them over the next 30 minutes. This question is from Cynthia and she says, “I was diagnosed with ET (Essential Thrombocythemia). I’m JAK2 positive,” so she has that JAK gene. “When I was 66 years old,” now she’s 68, I’m about to be 68 as well, “What markers on my blood work, asides platelets, are important for my doctor to watch? What indicates a need for another bone marrow biopsy?”

Dr. Pemmaraju: Well, thanks, Andrew. And thanks to the question from Cynthia out there. This is very important. This is what we talk about day-to-day, week-to-week in the clinic. There are a couple of perimeters outside of the platelets. One, I would say the most important for us to watch are the other of the big two. That’s your hemoglobin number, also known as anemia; if it’s too low, or polycythemia, if it’s too high, and then the white blood cell count is also very important. Again, if too high, or too low, it can tell us what’s going on.

With ET, the key thing is it can transform, or change into any of the other MPNs. For example, PV (polycythemia Vera), myelofibrosis, or – and I hate to mention it, but it does happen five, maybe seven percent of our patients, where the disease can go to Acute Myeloid Leukemia, AML. So, distinct blood count changes, either too high, or too low, can give us clues if the MPN is changing, or in fact, going to AML.

And so, the answer for a repeat bone marrow is based on that, which is, let’s look together, patient and provider to see if there are subtle or avert changes in the blood counts that are markedly different from the previous visit, rather than having a pre-prescribed, every three months, or every six months type of a deal.
Andrew: But, Naveen, with all you’re doing now with sophisticated testing, do you still have to poke us in the hip, or couldn’t they just do it from our arm?

Dr. Pemmaraju: I wish, Andrew. I think this is very important. I think with the juxtaposition, you have this sophisticated gene panel testing, JAK2 CALR, MPL, and yet we’re still sticking a needle in people’s backs in a very painful procedure. Nothing still has overmatched as the gold standard, the bone marrow aspiration biopsy. So, for now, we’re – pun intended, I guess – stuck with this procedure. But your point is a good one. For example, with bone marrow transplant, can you believe it nowadays, they’ve moved from not having to exclusively do it from bone marrow source to peripheral blood, so I think you’re on the right track and we need to work on different ways of accessing this important information.

Andrew: Okay. One thing about bone marrow biopsy, it doesn’t have to be painful. It’s uncomfortable, but it doesn’t have to be painful if you have somebody experienced doing it.

Dr. Pemmaraju: I wanna emphasize how right that is because at least here, at our center at MD Anderson, as you know, we have a team that is dedicated to doing it many, many people, many repetitions doing it, so there might be local discomfort, but a lot of our patients do not experience pain. I’m glad you brought that up.

Andrew: Right. And that’s been my experience both there, and at other major centers. Okay. Here’s a question from Denise. Denise says, “I have PV and I’m trying to improve my health by making smoothies containing large amounts of dark green vegetables, such as spinach, kale, and watercress. I’ve been warned by some members of our community that these foods will increase iron and raise the hematocrit, putting me at risk. Is that true? And should people with PV avoid these foods that are high in vitamin K?”

Dr. Pemmaraju: Well, this is an important question and I remember five to 10 years ago we would say things like, “Well, we don’t really know the answer,” or you know, “Diet doesn’t really have anything to do.” But now with more and more understanding of the total therapy for patients and approach to the whole body, I think this is an important question. So, yes, iron levels do matter. Too low, then you’re iron deficient. (That can definitely happen in our patients.) Too high, potentially may fuel the fire, if you will, for polycythemia Vera.

So, I think iron levels are important to watch and certainly can be increased by what our question is being asked about. But there’s another aspect, too, that some of the medications that we prescribe and take. One example is Coumadin, or Warfarin that a lot of our patients know, which is a high-level blood thinner. It’s an anticoagulant. And man, oh, man, that is exquisitely dependent on the vitamin K pathway. So sensitive, that in some patients in some cases even salad consumption, or spinach, so healthy foods because of the vitamin K level in them can alter this level. It’s called the INR. And so, it’s something we have to watch out for.

So, not only in terms of iron metabolites, but also drug-to-drug interactions. So, it is always best to mention these things when we’re going on new medications.

Andrew: Right. Talk to your doctor.

Dr. Pemmaraju: Talk to your doctor.

Andrew: What you’re doing –

Dr. Pemmaraju: Everything.

Andrew: – what you’re eating. Yeah. Okay. Here’s a question from Sally. Sally says, “I have ET with the MPL mutation. So, I have JAK, but there’s also MPL. I believe, not much is know about my mutation. Can you shed light on it, or me and our community here today?”

Dr. Pemmaraju: Yeah, great question. So, when I look at these mutations as the big three, I go back to the time of William Dameshek, who hypothesized in the ‘50s and ‘60s that MPNs would be a unified group of diseases; ET, PV, and MF. And now, 67 years later, we’ve proven that. So, JAK2, we’ve known about since 2005. The most common, most major recurring mutation, fifty to 60 percent of patients of myelofibrosis. Then in 2013, 2014 the CALR mutation was elucidated. Can you believe, that’s only been four, five years. That’s the second most common. But there’s a third of the big three. That’s the least common, the MPL; MPL mutation.

That’s a mutation in something called the thrombopoietin receptor (TPO), which is in charge of helping to stimulate and make platelets. So, in terms of MPN patients, it does make sense and it has something to do with platelets, and that axis. It is the least common; by far the less common of these three, so I would say maybe something to the point of three to seven percent of our patients will have it.
Up until recently, we didn’t know if it had any prognostic significance, but our Italian colleagues published a very nice paper in Blood a few years ago, independent of the IPSS risk, that I’m sure we’ll talk about later. That if you just take patients with myelofibrosis, not ET and PV, you can stratify our patients based on the mutation risk. And not everyone knows about this.

For example, in this scoring, CALR mutation alone is the best prognosis for our patients. JAK2, or MPL is what’s called an intermediate prognosis, and the so-called triple negative, if you don’t have any of these big three, the implication being that you likely have something else, like ASXL1, then those patients tend to have the worst prognosis. So, MPL helps us to diagnose and confirm an MF diagnosis, and it also may have prognostic significance in our modern era.

Andrew: Okay. I don’t want people to freak out because this is a moving target as they learn and say, “Oh, my god. I have triple negative…

Dr. Pemmaraju: That’s right.

Andrew: Right. Okay? Because there’s progress going on all the time.

Dr. Pemmaraju: Well said.

Andrew: This is what they’re learning now. Okay. Now. Here’s the big one and you mentioned it. You said, a small percentage of us with myelofibrosis have the risk of progressing to AML. I know there been a lot of new drugs now either approved, or in development for AML. And some that help people who have secondary AML.

Dr. Pemmaraju: Oh, yes.

Andrew: Right? But tell us about the risk of progression, and then what do you do about it?

Dr. Pemmaraju: Right. So, that’s a great topic, and as you know, you’ve been doing this for so long now. This has often been a very not great part of the conversation, but it’s an exciting time for our patients based on the research I’m about to share. So, the first part is progression to AML, which we touched on earlier. We do have an objective prognostics scoring system. Actually we have so many scoring systems now that many of our patients are starting to see them.

But the IPSS, or International Prognostics Scoring System, was first developed by our colleague, Cervantes et al, this is right before 2010, so ’07 to ’09. That one is supposed to be applied at diagnosis and based on five of these risk factors, we can prognosticate, or tell which of our patients are at a higher risk for AML. And so, a lot of our viewers ask that. So, it is true. Age – over a certain age, white count of 25,000, circulating blasts, constitutional symptoms, and anemia made up that original five.

Since that time, there are dynamic scoring systems, DIPSS, DIPSS+ and others that include, or modify as some of those risk factors. So, we can tell, at least based on a textbook impression, who has a higher likelihood of going to AML. Once our patients go to AML, there’s a lot of hope now. There have been four – count them – four new FDA approvals for AML in just the last 12-24 months. They apply to different segments of AMLs, two of them are targeted therapy, so one drug called Midostaurin hits the FLT3 inhibitor, one drug hits the IDH1 and 2. Actually those are two separate drugs.

The drug you were referring to had a code name CPX-351, or VYXEOS, and it does have an approved label for so-called secondary, or therapy-related AML. Although I will caution our viewers that – MPN patients, specifically, we’re not included in those early data sets. They were more geared towards patients with MDS leading to AML, but the principle is there for us.

And then finally there’s another drug called Gemtuzumab or Mylotarg. So, you have four FDA approvals, ongoing clinical trials with combination therapy, excitement and ongoing investigation for CAR-T cells, optimizing stem cell transplant, and then combining possibly MPN drugs with AML drugs in a clinical trial setting. So, I think this is actually a very, very important time to talk about AML in all of our MF and MPN sessions.

Andrew: Okay. Just one brief question, and – if someone like me, where I’m on Jakafi myself, but if that sort of poops out, or that, or another medicine is not working for me, and I’m developing AML, do you feel now it’s a more hopeful time than it’d had been previously?

Dr. Pemmaraju: I do, Andrew, and you know me. I used the word ‘hope’ very seriously and very carefully. Before with AML – and I mean, just five to seven years ago, it was not as hopeful of a time for us, as researchers, and for our patients. Not just because of the FDA approvals. That obviously is very encouraging and applies to a lot of our patients, but also because of the funding, the research, and the ideas for combination chemotherapies, and the emergence of these immune therapies. I think it’s a hopeful time for all of us involved with AML.

And specifically as you were mentioning this secondary, or post-MPN, or post-MDS AML, which is largely been an urgent unmet medical need.

Andrew: Okay. And just to everybody understands, AML, Acute Myeloid Leukemia, so it’s acute and as has been in the past a five alarm fire and now they’re developing medicines for that. All right. Let’s go on. Bonnie has a question. “I have myelofibrosis and my only symptom is that my spleen is enlarged. I’m on Hydroxyurea, but hesitant to switch to Jakafi or Ruxolitinib. Assuming no real discomfort and just moderate weight loss and stable blood counts, does an enlarging spleen itself cause problems?” And also, I guess the bigger question, Naveen is, is there a penalty for waiting if there is a treatment that might line up with what you got?

Dr. Pemmaraju: You’re right on. Yeah. This is very, very serious, important topic. So, for the first part of the question, the spleen itself being enlarged can in fact cause some really, really big problems for a lot of our patients. It is true, as the questioner’s asking, that one can have mild splenomegaly. So, a spleen that’s slightly enlarged, not yet causing physical symptoms of early satiety, which means getting full fast, or physical discomfort, but a lot of patients do have that. So, yes, a big spleen alone can cause not only local problems, but also systemic. Because again, it’s a disease of cytokines; messengers and proteins that are being scattered all throughout the body, causing the body to feel flu-like symptoms, or fatigue.

Now, the studies for Ruxolitinib are very specific. These are two Phase 3 studies, they are called Comfort 1 and 2, published in the New England Journal five six years ago now. And they did include patients with intermediate to, or high-risk disease. Or intermediate to high-risk disease, shall we say. And although the spleen itself doesn’t come out in the scoring system, some position is that it should be patients with more advanced, or higher scoring diseases than say someone with lower risk disease.

So, with the trial data that we have we know a couple of things. 1) The drug got approved in those more advanced patients. 2) There was early crossover that was allowed. So, one of the comfort studies, Andrew, was as you know, randomize to placebo. So, no active therapy, and one was best available therapy. Even with the early crossover allowed to the Ruxolitinib, both are not showing overall survival benefit. Translated into more layman’s terms, what that means is, it does appear, maybe, possibly, that if you got the drug at the beginning early on, there looks to have been some long-term benefit.

We won’t know that until further studies are done, and those studies are being planned. Those are called ‘early intervention’ studies, so people at a lower, earlier stage, low risk, Intermediate 1, and I think we’ll all be eager to see how that benefits our patients.

Andrew: Okay. Great. So, the penalty for waiting – right now it appears there could be a penalty. In other words, it could be better to get on it. Don’t wait. If you and your doctor agree, there’s a therapy for you.

Dr. Pemmaraju: I think that’s exactly the resource position to take, which is I think that – I believe that there are a subset of our patients who exactly fit what you said. They are symptomatic, out of proportion to the risk scores that are available. The spleen is highly enlarged, although they have lower intermediate risk by IPSS. And that’s exactly the are of investigation for myself, and our colleagues. And even in the clinic there might be some role to assessing patients as you said like that. So, it shows you the limitation of these text book scoring systems and how much research we have left to do.

Andrew: Okay. Well, you know more than you did before, so, I –

Dr. Pemmaraju: Well said.

Andrew: – I’m happy about that. Okay. So, here’s a question from Jane. She says, “I have myelofibrosis, but it’s not progressing, and I’m CALR negative.” So, that’s one. “I’m JAK negative.” That’s two. “And I’m waiting to hear if I’m actually triple negative, as you said, which would be JAK, CALR, and MPL. Are there medicines to slow progression for me?”

Dr. Pemmaraju: Well, that’s the ultimate question. Isn’t it? So, the first concept is this triple negative. And if our viewers have heard that before you have, that was borrowed from the breast cancer literature, which was a similar sentiment, which is having the top three markers negative. And just in that case, as in RMF, the supposition is the same, that that means that you have a higher risk disease.

But going from negative to positive, what it does mean now with the new sequencing and molecular studies that are coming out, is that it really looks like 90 percent, maybe even close to a 100 percent of patients, have some form of a molecular driver. And those other mutations you’re going to start to hear about are becoming common; ASXL1, TP53, EZH2, IDH, etc. etc. So, triple negative may mean that we don’t have those big three, but there might be something else that’s driving the MF, and it means that it’s a higher risk to progress to AML and for some patients to not do as well.

But this questioner brings up a very good point. What the textbook risk score says does not have to imply to each individual patients. So, just because the finding is that, okay. Triple negative patients as a population may do worse, it may not apply to that individual patient. So, in this person’s case, maybe they’ve been diagnosed very, very early. That’s a good thing. Maybe the driver mutations and the triple negative matter, which is what I think. So, ASXL1 mutation vs. some other ones.

And then finally, each patient is different. Everyone’s case is different. You have other co-morbidities, other underlying drivers of disease. So, I think that’s the good point. But, we do have to say, at least for right now, I like your phrase ‘of a moving target’. The understanding that if you are this triple negative disease in this classical sense, should mean that you are a higher risk at some point to progress, as compared to others in your group, and so, possibly closer monitoring and observation is necessary.

Andrew: Right. And see an MPN specialist. Because what if there’s a drug in development that’s an AS – What is it? AS –

Dr. Pemmaraju: ASXL1.

Andrew: Inhibitor. And that’s driving your bus. Right? Maybe you wanna be in that trial. [

Dr. Pemmaraju: Absolutely right. Clinical trials are important for all of our patients with any rare cancers, or any cancers in general.

Andrew: Right. Okay. Let’s go on. I just wanna take this question from Susan. It really rang true for me. Susan writes, “Is it common for an ET patient to experience numbness in the scalp, ears, and face? I’m currently on 1,500 milligrams of Hydrea daily.” And I wonder if you can broad this out because I was telling you before the program, I’m getting every once in a while – I wake up with a little prickliness. Not itchy, and I go back to sleep, but is that related to my MPN? So, she has scalp questions, is it the MPN, ET whatever? Is it the medicine?

Andrew: This is coming up in my clinic on a weekly basis. The short answer is, yes. It’s always due to the MPN. And I’m here to tell you why. This is an underappreciated part of what we do as healthcare providers in patients. For anyone who’s ever filled out the Myeloproliferative Neoplasm (MPN) Symptom Assessment Form Total Symptom Score:, developed by Ruben Mesa, his colleagues, now shortened down to a nice, nifty 10 ques – sheet. You know, actually, peripheral neuropathy is one of those 10 questions. Do you have numbness and tingling? So, even though we don’t talk about it, that’s our fault, peripheral neuropathy is a thing. It’s a common aspect of the MPN.

No. 2 is – and you brought this up to me nicely as well, is some of the mediations that we prescribe at the chemotherapeutic level can also cause nerve damage and neuropathy. JAK inhibitors either as a class, or some of these individual ones, both FDA approved in clinical trials have been associated with either a central, or peripheral neuropathy. So, I think that’s another big aspect.

And then finally, I hate to say it, but these drug-to-drug interactions of all of these medicines can cause that. When you factor that, plus vitamin deficiencies, thyroid deficiencies, iron abnormalities, restless leg syndrome, our patients have a host of reasons to have neuropathy. Usually this is an intermittent phenomenon, a come and go phenomenon. When it starts to become more of a permanent phenomenon and progressive, that’s a big concern, and that would really require a separate neurologic work up.

True, there are some chemotherapy drugs that can cause that, but I would say that would necessitate a multi-disciplinary approach; neurologists and all of this kind of thing.

Andrew: Okay. You used the name of a drug that people take. Is a blood thinner, Coumadin. Somebody may take diabetes medicines, I also have Chronic Lymphocytic Leukemia and take medicines for that. Okay. So, if we’re developing some of this and we have an MPN, which of the many doctors we have doo we go to first – do we go to you as our MPN specialist? Do we start there?

Dr. Pemmaraju: Yes. Absolutely. I think the phrase and the motto of every MPN expert that you’ll meet (and you and I know all of them now) is, ‘Tell us everything.’ Because I will tell you what. Now that we have more understanding – not full understanding yet, but more understanding of the biology of these diseases, it turns out that a lot of things that are happening are due to MPN.

One example I’ll give you, Andrew, our colleague and friend, Claire Harrison has pioneered this phrase called, ‘presenteeism’. Presenteeism. Not absenteeism, as we learned when we were younger. The concept that our patients with MPN are there, they’re here at work, with their loved ones, they’re at dinner, but they’re not really there. That’s also a question on the questionnaire; inability to concentrate. Subtle, subtle, subtle, but this is part of the MPN process. We’re not talking about it enough, but programs like this will get the message out there. So, tell your MPN doctor everything because more than likely they know it’s part of the MPN.

Andrew: I gotta tell my wife. I’ve been married 33 years.

Dr. Pemmaraju: This is all recorded, so you can tell her.

Andrew: All right. Esther, where are you? Okay. No. Let’s go on. So, Heather sent in this question. “My local hematologist, oncologist will only give me a phlebotomy after my hematocrit is over 51. What is the standard marker? I have PV and I’m really struggling with symptoms.”

Dr. Pemmaraju: I actually have data to share with you and your viewers. So, before four years ago, we did use to do it either based on convention, symptom burden, or a pre-designed abstract number. But now we have data. So, our Italian colleagues, Barbui and colleagues published in the New England Journal about four years ago a very nice paper that starts to answer this question. They randomize patients with P. Vera to two groups. They called it a liberal group, where you could get phlebotomies at any number essentially just like what’s being asked here, and then a more stringent group, which they came up with the hematocrit goal of 45 and below. Or below 45.

And the trial was actually stopped early because it showed a four-fold decrease in cardiovascular morbidity and mortality. That means, four times less chance of people having cardiac events or cardiac deaths in the stringent phlebotomy group. That is when you put the goal below 45. Yes, it’s only one study, but it’s with several hundred patients with P. Vera in a nice controlled situation. So, that has become a lot of us – for us, the de facto of standard of care.
So, I would advise, if you’re a higher risk patient with P. Vera, the so-called triple therapy approach, where you’re doing, you know, baby aspirin if you qualify. The phlebotomy goal of 45 and below, and then of course, cytoreductive therapy if you need it in the higher-risk situation. So, 45 and below, it should be validated, we should do more studies here in the States, but that’s something that I think we can use with high-level data.

Andrew: Okay, thanks. Here’s a question we got in from Kimberley. She says, “My daughter is 22, she was diagnosed in 2013 with ET, and she’s been on Hydroxyurea, but is decided she no longer wants to take the med. What should she be aware of, or cautious about, given that she’s no longer taking it?”

Dr. Pemmaraju: Ugh. Well, this is an area that’s very dear to me and very important to my research. With our group here, with Dr. Serge Verstovsek and my colleagues, we just published a paper on our experience with adolescents and young adults with MPN, or AYA. As its own separate field, AYA cancer has become a very important understanding that really didn’t exist, in my opinion, 20 years ago. But our patients are not always older patients. So, young patients can get MPN, too. Yes, patients in their teens and twenties can get them just like this questioner.

So, this is a type of patient that I’m seeing quite commonly in the clinic. Couple of points to say. One is, who can blame her? Who wants to take a life-long, indefinite oral chemotherapy that may or may not have short-term and long-term side effects? In our study what we found is, approximately 10 percent of our patients met this definition. The NCCN gives it, I think, age 16 to 39. So, younger than 40. And out of those patients, I was surprised to see that a good seven percent had a thrombotic event. That means a blood clot, either at the time of diagnosis just prior to, or just after. Well, that’s a pretty good clip, and that would be more than the general population than what you would expect.

The problem with the young patient with MPN has several issues. One is, what about at the time of fertility and pregnancy? Two, what about at the time of surgical procedures? I’m talking about routine things, such as dental and other care. And then three, as they start to transition into their older adult years. So, in this patient’s case, this is a very difficult thing. We don’t have many drugs. We have Hydroxyurea, we have Interferon, which possibly might be better for a younger patient. If someone has myelofibrosis, there’s no age requirements. So, if you qualify, then the JAK inhibitor, as a class.

But this is just one of those in-between, vulnerable populations, and we really don’t have great treatments for in general, an AYA cancer, and specifically here. And so, the main thing that we would say to this person is, really, really close follow-up early on with an MPN expert, as you always advocate. Two, is at the time of fertility planning, pregnancy in our family planning is to have high-risk maternal-fetal experts involved early on. (I think, this is something important.) And three, really cautious planning in and around surgical procedures, looking for bleeding and blood clots. I think those are some basic guidelines for anyone to follow.

Andrew: Well, great advice for mom and daughter. I wanted to post this, just a quick question from Caroline who lives in the United Kingdom is diagnosed with primary myelofibrosis four years ago at age 49. And she said, “I’ve tried to find others with myelofibrosis of a similar age, but so far no luck.” So, is being diagnosed at her age, age 49 with myelofibrosis, unusual?

Dr. Pemmaraju: There you go. That’s perfect. So, that also goes along with our “Young people get MNPs as well.” This was a disease – first of all a disease, now we recognize it as a cancer that was thought to be 60, 70, 80, 90 and older. And now we realize that there’s a significant subset of our populations diagnosed in their teens, twenties, thirties, and forties. So, we definitely want our question – our viewer to know, no, you’re not alone at all. Please, see our paper that we just put out there and several other of my colleagues, including Brady Stein and others.

Two is, my goodness. Not only you’re not alone, but I actually believe – and I know you know this too – that a lot of rare cancers are sometimes are under diagnosed and underappreciated. It does require expert bone marrow, expertise, someone to identify it, someone to do a bone marrow. And lastly, for this patient looking for other patients, I would refer them to sources, such as this one. Patient Power, support groups on Facebook, we have a Twitter feed, as you know, a grassroots Twitter, that’s investigators initiative called #MPNSM (myeloproliferative neoplasm on social media).

So, there are lots of different ways for this person to connect with not only younger patients with the disease, but also as a support group, virtually. And I think platforms, such as Patient Power, have frankly revolutionized the way people have obtained information, have communicated with each other, and specifically for a patient like this in the UK, who is not able to connect with me. And when there are people all over the world waiting to talk to her.

Andrew: Right. I wanna call at our friends in the United Kingdom, MPN Voice.

Dr. Pemmaraju: Oh, yes.

Andrew: It’s Claire Harrison, who you mentioned, wonderful, devoted.

Dr. Pemmaraju: Outstanding.

Andrew: She’s an expert, out of London, helps run it. So, please, connect with them. Okay, here is a question from Erin, as we’re getting near the end of our program. “Can ET ever cause systemic inflammation? And is that what causes symptoms? The inflammation.”

Dr. Pemmaraju: Yes, yes, and yes. So, inflammation, I think, used to be a word that may have been potentially, if I may say, a wastebasket term, but now is a very specific term. So, now we know that a lot of our hematologic disorders and malignancies lead to a high level of inflammation. That means tissue damage. Tissue injury. That’s what inflammation means. There are some conditions that the patient does not even have a blood cancer diagnosis, but has a molecular mutation, that’s called CHIP (clonal hematopoiesis of indeterminate potential), and those patients appear to have a higher likelihood of cardiovascular disease and death. That’s New England Journal of Medicine. The likely pathway is inflammation.

In our patients with MPN, even the quote on quote, earlier stages, such as ET and PV. This is a disease of cytokines and inflammation. So, high levels of abnormal messengers and signals. So, yes, inflammation is part of the disease, patients have a higher rate of cardiovascular events and death. That’s inflammation. And then of course, the bone marrow milieu itself, as it progresses to myelofibrosis has an up ramp, if you will, of cytokines and inflammation. Last part of it is the therapies that we’re working on are trying to either target inflammation itself, or to bring down that level.

Andrew: Okay. I wanna see if – Here’s a – one that just popped in as we get near the end of our program. Roger says, “Are there any drugs being studied that improve anemia in patients with a low hemoglobin?” What’s the easiest way to find out about clinical trials if you live out of the state, or out of the country where this trial may be –?

Dr. Pemmaraju: Yes. Your best resource to look that up is run by the Federal Government, the NH, it’s called clinicaltrials.gov, that’s dot G-O-V. This is an outstanding website, well curated, updated as quickly as they can, and it has a nice search function. You can search by investigator, disease type, condition, and there’s even a box for ‘other’ where you can type in something like ‘myelofibrosis’.

There are several drugs in development. These drugs are known as Luspatercept and Sotatercept, for example. And they’re a class of drugs that are anemia targeting in myelofibrosis and myelodisplastic syndrome. So, the answer is, yes. And you can find out these types of clinical trials either online at this website, or at other websites. But this is an important, urgent, unmet medical need that we are working on, and there are active clinical trials for patients to enroll on.

Andrew: Well, okay. And the last thing I would ask you about – and this always comes up, Naveen, but I wanna hear what you have to say is somebody we have people with ET, we have people with PD, MF, and we talked at one end about acute myeloid leukemia. What do we know about progression now? So, if I’m sitting there with ET, am I necessarily going to go onto PV, or MF? Or anywhere along the line, and how do we know?

Dr. Pemmaraju: We do know a little bit more. So, the answer is no. So, a lot of our patients do stay in the chronic phase, as you’re asking. So, if you’re ET, or PV – and our European colleagues have really done these nice population studies, where the majority – the vast majority of patients with ET and PV are expected in the modern era to have normal life expectancies as long as you’re mitigating in some bleeds, clots, and these type of events.

But for the minority, who don’t have a normal life expectancy, you’re talking about progression to AML, which is a minority of all these. Right? Maybe 5-7 percent of cases at the most. There are some things we have identified. One is that there are some dynamic acquisition of molecular mutations that are happening at the time of progression. And what I mean by that is, there are new injuries to the DNA that people appear to be picking up. So, two important studies our colleague, Raajit Rampal showed that the acquisition of TP53 mutation, which is the guardian of the genome present in 50 (five, zero) percent of human cancers. That looks like it’s more common when ET and PV are trying to take off to AML.

Another study by our Mayo colleagues just published in Blood Advances showed that other mutations, such as PTPN11, or RUNX1, just to name some particular ones, and then we’ve known about ASXL-1 now for a while. So, rapidly change in blood counts in concert with new molecular mutations, and then a baseline if you have high-risk mutations. That seems to be a way for us to predict who might transform faster than others.

Now, that’s an addition to the traditional risk factors that you and I have already discussed, the IPSS risk, or etc. So, there are some ways that we can monitor. A lot of these may be in the research setting. Some are ready for the clinic, but there are some ways now.

Andrew: Okay. So, ladies and gentlemen, I hope this program is been worthwhile for you. Remember that the big meeting of Dr. Pemmaraju and his colleagues from around the world with thousands of hematologists is this the American Society of Hematology meeting, which once again, will be, yay, near me, in San Diego.

Dr. Pemmaraju: Very good.

Andrew: Esther and I’ll just drive over. And the Patient Power team will be there, the Patient Empowerment Network team will be there. So, we’re there for you. So, look for more programs as we go through the fall, and certainly in December, when this meeting happens. And that’s where a lot of the research that Dr. Pemmaraju talks about is presented.

Dr. Pemmaraju: Right.

Andrew: And then we’ll have more news. So, we’re living with these long-term conditions, thank god for most all of us, and it’s a moving target, as I’ve described. I wanna thank you for joining the Patient Empowerment Network program, for sponsoring this program. We thank Incyte Corporation for its support, and Dr. Naveen Pemmaraju from M.D. Anderson, and the Leukemia Department there, thank you for being a partner in this, and just explaining things, and your passion. And Naveen, again, back to your whiteboard back there. Figure it out.

Dr. Pemmaraju: It’s all there. Yes, sir, Andrew.

Andrew: It’s all there. Figure it out. Okay? All right. Thank you so much for being with us from around the world. We love it. We’ve got a community. This is what it’s all about and we’ll have future ask the expert programs. I’m Andrew Schorr near San Diego. Thanks to the Patient Empowerment Network for making all this happen. Remember, knowledge can be the best medicine of all.

Spotlight On: Patients Have Power Campaign

We are  proud to announce that we are official participants in the Patients Have Power campaign run by Clara Health.

This campaign is a nationwide initiative aligning thousands worldwide around one message: Patients. Have. Power.

The movement is comprised of patients, caregivers, allies, nurses, doctors, researchers, members of the healthcare workforce and anyone and everyone who believes in patient power all around the world.

This year’s campaign theme is entitled “Taking Patient Power to the Streets: From Hospitals to Hair Salons.” With digital being all the rage, we’ve increasingly seen advocacy and awareness move on line. While this is an exciting and effective way to reach a large audience, we believe boots on the ground, in-person initiatives are equally important. Healthcare should be human.

At Patient Empowerment Network, we believe patients should be empowered with the knowledge and resources they need to hold the ultimate power in their healthcare journey and are proud to say that we live the mantra: Patients Have Power.

We’re so excited to once again join in on the #PatientsHavePower campaign. Interested in getting involved and helping spread the word? Show your support by participating in the following:

  • Help raise boots on the ground awareness and drop off Patients Have Power magazines filled with patient art, essays, and stories at local community hubs.

  • Participate in the #PatientsHavePower Twitter Chat on October 2nd

  • Post a photo holding up a Patients Have Power sign.

  • Attend a Patients Have Power mixer in San Francisco or NYC.

Myeloma Patient Cafe® July 2018 – Best Practices for Coping with Side-Effects and Symptoms

Cindy Chmielewski (@MyelomaTeacher) leads a panel of six patients diagnosed with Multiple Myeloma. The panel discusses the symptoms of their disease and some ways to cope and manage those side effects.


Transcript:

Cindy Chmielewski:
Hello, everyone, and welcome to the Myeloma Patient Café. We would like to thank our sponsors, AbbVie, Celgene, Sanofi and Amgen for their generous support.

Today we’re going to be discussing ways of coping with and managing side effects from treatment and some of our symptoms from multiple myeloma. Before we begin I want to make sure that you understand that this is in no way going to replace your conversations that you have with your physicians, but you could use this as a springboard to start some of those conversations.

I am delighted that today we’re going to be joined by other myeloma patients who have found some successful ways of coping with their shot side effects and are willing to share. So before we get started, let’s just introduce ourselves and tell us a little bit about yourself, where you live, when you were diagnosed, and maybe one or two of the two most challenging side effects.

My name is Cindy Chmielewski. I live in Laurenceville, New Jersey, and I was diagnosed with multiple myeloma in July of 2008. And some of the challenging side effects that I feel the most frustrated about are the fatigue that I have and chemo brain. And why don’t we go next to Sarah.

Sarah Frisbie:
Hi, I’m Sarah Frisbie, and I am from Nebraska, Omaha, Nebraska. I was diagnosed in November of 2011 after a hip fracture. My hip broke. And I think the most challenging side effects I’ve dealt with, probably digestive issues with Revlimid and some nausea, so that’s probably been the most.

Cindy Chmielewski:
Okay. Great. Lynn, how about you tell us a little bit about yourself.

Lynn Worthen:
I was diagnosed in a routine physical in April of 2010, and the doctor there confirmed the diagnosis. He was a GP, but he confirmed it and sent me to Little Rock, and so I started treatment there. I’ve had the routine side effects, the fatigue you talked about, no appetite, no energy, that sort of thing that all kind of went with the transplant phase that I had, but beyond that I wasn’t severely bothered by too many things. I didn’t have neuropathy. I didn’t have a lot of nausea. They gave me a lot of pills for that, and so those things worked pretty well.

I think‑‑I don’t know how everybody else had it, but they gave me 40 milligrams dexamethasone a day four days and stuff like that, and it was interesting to negotiate that. The lack of sleep, the retention of water. I gained 17 pounds in four days, you know, all that kind of thing. But those passed after a while when we stopped with the extreme level of dexamethasone and I got it out of my system. But pretty much the routine kind of side effects that people have.

Cindy Chmielewski:
Okay. Great. I can’t wait until we get into the conversation of ways people managed dealing with some of their side effects and negotiating their dosage of dex. Paula, how about you?

Paula Waller:
I live in central Virginia, and I was diagnosed in April 2014 and had a transplant in November of that year, did consolidation, and I’ve been on maintenance ever since. The first side effect I really noticed was some neuropathy, not the painful kind but the kind that’s more bothersome, numbness, just weird feeling. And I do have some nausea, which is now very well controlled that’s associated with (? Phonetic nemoro) that I take as part of my maintenance routine.

Cindy Chmielewski:
Okay. Jill, a little about bit yourself.

Jill Zitzewitz:
Yes, I’m Jill Zitzewitz, and I live in Massachusetts, and I was diagnosed in March of last year after a series of compression fractures in my spine. It took them a while to figure out what was going on, but once they did we got into treatment. And I think my major side effects have been still the back pain from the compression fractures. Even though they’ve healed I still wear out as the day wears on. I need to sit on my heating pad at the end of the day. And then the major one probably for me, I’m rashy girl. Every drug, I get rashes everywhere, and so that’s been a bit of a challenge to deal with.

Cindy Chmielewski:
Okay. Steve, introduce yourself a little bit.

Steve Simpson:
Yeah. I’m Steve Simpson, I live in Tea, South Dakota. We’re just outside of Sioux Falls, South Dakota. I was diagnosed in November of 2015. That was actually brought about through an MRI that showed up having six vertebrae that were pretty much completely destroyed by the tumor. Spent the next morning in about six hours of surgery and have gone from there.

Side effects, I’m going to say the worst ones are obviously neuropathy was a big one. Syncope was probably the biggest one I had to overcome, and then the digestive issue, I feel your pain on that one. That’s just not real enjoyable, but we’re getting there. So those are the things that‑‑that’s just a few of the many we have, but those are probably some of the big ones for me.

Cindy Chmielewski:
Hi, Melissa, welcome.

Melissa Vaughn:
Hi.

Cindy Chmielewski:
We’re introducing ourselves, where we’re from, when we were diagnosed and some of the major side effects that you have experienced.

Melissa Vaughn:
Okay. Want me to go ahead?

Cindy Chmielewski:
Sure.

Melissa Vaughn:
Okay, Melissa, and I was diagnosed 18 months ago, back in February of 2017. I have to think about that. And I’m from Dallas, Texas. And some of my symptoms were a lot of neuropathy in my hands and in my feet, some numbness. And I definitely had some spine issues as well, some pelvic lesions and so pelvic pain. And so I also have lesions in my hip and then I had a hairline fracture in my leg, so.

Cindy Chmielewski:
Okay. So it sounds like we have a lot of issues to deal with. Some of them are caused by the disease itself like back pain causing some of the compression fractures, and neuropathy I heard can be either caused by the myeloma or by the drugs that treat myeloma. And then we have side effects from the treatment itself.

Just to begin with, were you surprised by the side effects you were experiencing, or were you prepared to deal with them? Anybody want to‑‑

Steve Simpson:
I will. I don’t think you are because you really don’t know what you’re getting into.

Cindy Chmielewski:
Right.

Steve Simpson:
You walk into this blind to begin with, thinking‑‑you know, they can tell you what they want, and that’s fine, but everybody reacts different. And I think that’s the big thing everybody needs to understand. From my standpoint, when we got into the chemo, you know, the Velcade and all that stuff, I didn’t have anything really from that I had to worry about other than neuropathy which is‑‑you know, Velcade is a big factor in neuropathy and that being nerve damage doesn’t go away. You can manage it, but it’s going to be with you until, you know, whenever.

So, yeah, I would hope that most everybody is surprised for the most part because you don’t know what to expect. You don’t know what’s coming from any of it. They can talk about the chemo brain, which, I don’t know about the rest of you but when I heard that I kind of laughed. Well, I don’t laugh anymore because it’s sad but it’s there. So from my standpoint, yeah, I think they’re all kind of unexpected. The biggest one probably aside from those was the heart damage that I had that was the beginning of the syncope (? Inaudible) from the start where the left ventricle, the damage down to 35 percent, and so we had to kind of fix that problem first and then go from there, so.

Cindy Chmielewski:
Anybody else? Anybody knew what they were getting into, or was everyone else surprised?

Melissa Vaughn:
Well, I’ve been a therapist for 15 years, an occupational therapist, so I was familiar with multiple myeloma and kind of had a feeling I had it before I was diagnosed it before I was diagnosed. So going into it I kind of knew a little bit about neuropathy and some of the side effects, but just like what was just mentioned that it’s so unique to each patient, and it was very unique to me, my side effects. So like he said, you can imagine, they can tell you what the experience may be but until you do it yourself it’s difficult to predict.

Cindy Chmielewski:
Yeah. I think that’s something we need to stress. Every patient is going to respond to treatment and their myeloma differently, so whatever we’re saying today may help, may not help, may be something you’re experiencing, it may not be, but it’s just good to hear from each other.

We keep on hearing about neuropathy. Has anyone found ways of dealing with or managing their neuropathy?

Steve Simpson:
Well, I’ll be honest with you. With mine, I’m on 2700 milligrams of gabapentin a day, which is about as much as you wanted to take because that’s nine pills a day. Plus I’m on duloxetine, which is an additional drug for that, but in that I had to take away my amitriptyline for sleeping at night because those two contradict each other.

And then we just recently in my last thing, it wasn’t yesterday, it was the last month going in for my monthly we dropped my dexamethasone down because that’s another factor in neuropathy. My hematologist just decided to take the once‑a‑week dex and cut it down and see what that does, and that has helped a little bit. But even that sometimes isn’t enough because my feet are continually numb on the bottom. I refuse to walk around barefoot anywhere in the house. I mean, it’s just‑‑there’s little things that drive you nuts and you can manage to a point, but that’s about as far as it goes.

Cindy Chmielewski:
We talked about some drugs like gabapentin.

Steve Simpson:
Gabapentin, yep.

Cindy Chmielewski:
Who did you work with with those drugs? Was it your oncologist, hematologist?

Steve Simpson:
Yeah, all of this is through my hematologist, correct. Everything I’ve done drug‑wise related to that part of it where it’s related under that section of the cancer is through my hematologist. I have some other things we do obviously through cardiology or pulmonary and those types of things, but that particular one was with the hematologist, correct.

Cindy Chmielewski:
Anybody else have ways that they worked with their neuropathy?

Jill Zitzewitz:
I think for me my neuropathy was much worse before I was diagnosed, and actually it cleared some, which was surprising to me because that was supposed to be a huge side effects of the medications that we take so I was expecting it to just get worse and worse, but that wasn’t a side effect for me. It was more of a myeloma issue, so.

Cindy Chmielewski:
So as your myeloma was getting better your neuropathy was getting low.

Jill Zitzewitz:
Yes.

Cindy Chmielewski:
Anybody else about neuropathy?

Melissa Vaughn:
Exercise, exercise helps me most.

Cindy Chmielewski:
Yeah. I was told a long time ago that maybe a vitamin B‑6 type of supplement may help with neuropathy, so I asked my doctor and he said it couldn’t hurt so I’ve been taking it. I don’t know if it’s helping, but it’s not hurting according to him, so that’s something else maybe that you could consider. Any other body doing anything else there?

Paula Waller:
I take supplements. Actually, I have three things that I do for neuropathy. My neuropathy isn’t terrible, it’s more bothersome, but I do take a B complex vitamin which my doctor recommended soon after I was diagnosed.

I was stunned when my feet went numb within a week of my first Velcade shots, and I began researching, and one of the things I found was people were using acupuncture. And I was skeptical but decided to give it a try, and it has really helped a lot. What I find is I need to keep on a somewhat regular schedule with that. If I go a few months without it then the neuropathy worsens.

The other thing, someone said exercise, and I found that Dana‑Farber’s website has an online health library with a wonderful slide show of very simple exercises that can be done for feet, legs and fingers, and again something that I find I need to keep up with regularly for it to really help, but if I do it does help.

Cindy Chmielewski:
That’s good to know. And talking about acupuncture. Has anyone else used acupuncture or any of the other like mind‑body type of interventions, maybe yoga, meditation, anything like that that may help with certain of your side effects?

Jill Zitzewitz:
I definitely have been doing a lot of mindfulness since then and I think it has helped just with overall anxiety that comes along with disease and everything to kind of keep that under control. So just spending a few moments at the start and end of every day just being mindful and peaceful.

Cindy Chmielewski:
Can you describe a little bit about what a mindfulness practice looks like?

Jill Zitzewitz:
So for me it’s just‑‑really just a centering moment where you just really focus in on, maybe my finger, my knee, maybe the‑‑oftentimes it’s the tree outside my house that I can see in the yard and just kind of really just noticing that. Just noticing the tree or sometimes noticing the birds singing but just letting everything else go away while you focus very much on one particular item.

Cindy Chmielewski:
Okay. I did some mindfulness training at one of our support groups, and it seems like something that would be very beneficial. I really need to try a little bit more of that practice. Maybe that would help a little more.

How about pain? Ways of dealing with whether it’s back pain or any type of bone pain. Anyone have suggestions?

Jill Zitzewitz:
So mindfulness definitely has helped with my pain as well. I seem to be able to kind of forget about it for a bit. Another thing that really for me, I’m in love with my heating pad, so I find for my back at the end of the day I just need to sit on it, so I’ll have the air conditioner blaring so I can actually sit on my heating pad and kind of get some relief that way.

Cindy Chmielewski:
Anybody else have ways of dealing with back pain, bone pain?

Sarah Frisbie:
I’ve had quite a bit of back pain and hip pain. Those are areas. My back I had compression fractures, and so even after they healed it kept hurting. But after I had the fractures they gave me a brace, and I just wear that. If I know I have to sit or walk for a long time I just wear the brace and that helps a lot. Because I try‑‑when I first had the fractures I had to take the hydrocodone, but I try to stay away from that if I can. I don’t like the side effects.

Cindy Chmielewski:
And you said they gave you a brace. Who is “they”?

Sarah Frisbie:
Oh, my gosh, I can’t‑‑it was ordered. I saw like a neurosurgeon.

Cindy Chmielewski:
Okay.

Sarah Frisbie:
And he ordered it, and I can’t remember the name of the company, but like I was fitted for it, and it’s bulky and awkward to wear, but if I’m going to go somewhere and I have to fly and sit upright on a plane or something I will wear that. It’s kind of like an exoskeleton or something. It holds me up and makes it hurt less.

Jill Zitzewitz:
My cane does that for me too. For a while I was barely able to walk and was using a walker and then a cane, and I don’t need it anymore, but if I need to stand for any length of time I am in a lot of pain, and I find if I have the cane I can at least stretch up a little bit and do a little stretching and manage to get through that pain.

Sarah Frisbie:
Yeah.

Cindy Chmielewski:
Anyone else have to deal with some back pain or bone pain?

Steve Simpson:
The back pain came from the surgery, and that’s going to be an ongoing thing for me. I don’t think I’m ever going to get completely away from that. It’s more like, when we’re sitting right here I’ll tell you right now, after so long the position of the neck or the (? Inaudible) support back here because of where the surgery was will create that bit of discomfort or pain.

Now, again, I can’t remember who just said hydrocodone is a big no, and it is. In the beginning when I went through this and put up with it for three and a half months before I even did anything I refused any pain medicine whatsoever, so I’ve got a pile of hydrocodone sitting, hidden away because I won’t take it. What happened was we went to tramadol and a lidocaine patch to just kind of simplify that problem.

Lidocaine patch is nice just because it’s simple to put on, it’s quick, and it does provide enough relief for me to not have to worry about taking anything else. Now, again, it’s more of a‑‑I don’t want to say now a pain as it was initially. It’s more of a discomfort because there are muscles and nerves that didn’t quite heal right, so I’ve got two vertebrae that actually stick out back there where the scar is at, and through all of the weightlifting that I do now on a regular basis that gets pretty tender pretty quick. So I rely on those lidocaine patches and Tylenol every once in a while to get through that.

Sarah Frisbie:
You know, I was going to say another thing that was really effective for me that I use sometimes but it’s kind of awkward to get it in the right place is a TENS unit, the little electrical stimulation. And where it’s at, where the pain is on my back it’s kind of hard to reach, but if I can do it I’ve done that and just worn it all day and periodically turn it on, and that will help me if I have to sit somewhere for a long time. Because the only thing that really, completely relieves it is leading way back in a recliner or just laying down in my bed, but, you know, I can’t do that all day, so.

Cindy Chmielewski:
Right. I find that my pain is worse if I stand in one place for too long, so I try to move positions, not stand in one place. Sometimes just sitting down for five minutes, getting off your feet and restarting whatever you’re doing helps with my back pain.

Lynn Worthen:
You know, you all‑‑I haven’t said anything. I’m listening because, as I said earlier, I haven’t had a lot of issues with side effects. Pain, I don’t have an explanation for this but I don’t‑‑I feel pain like everybody else I guess, but I don’t‑‑I don’t necessarily experience it like everybody else. I haven’t had much pain at all through this. I had, as Melissa said, I have pelvic lesions and a pretty good size one on the left iliac wing. I learned that big term through all this.

And I’ve had‑‑been curious as I’ve travelled and spoken at support groups to ask people how many like bone marrow biopsies they’ve had or fine needle aspirations they’ve had. In Little Rock they do them in abundance, and in eight years I’ve probably had, oh, I don’t know, 30 or 35 bone marrow biopsies and fine needle aspirations. And everything is done‑‑you’re awake. Unless you have to be sedated you’re awake, and so I just lay there, and they do what they have to do. And I feel certain things but I don’t‑‑it doesn’t hurt me that much. I just lay there and do it.

Like right now, see, I wear boots quite a bit, and my right toes on my right foot are a little bit numb, but if I take these boots off and walk around, the exercising part, that little bit of neuropathy will go away. But it is helpful to hear what you’re saying because all that could change. All those things could be different.

And as I talk to people around the country everybody‑‑you said earlier, Cindy, everybody experiences this stuff differently. It’s just there are commonalities in all that we do, but it’s never going to be exactly the same for everybody. It just doesn’t work out that way, and we can encourage one another and help each other with information that we’re gathering in places like this to know what to do when you have certain kind of things happening to you.

So I’m grateful that I don’t feel certain things, I haven’t experienced certain things. And I’ve had lots of Velcade, I’ve had lots of dexamethasone, and I was in remission. And I had a small, truly was a small relapse, and then I had three years of treatment that ended back in May, and through all of those things from the beginning, the stem cell transplants‑‑I had two of them. I had two stem cell transplants in a span of about 10 weeks, and that again is part of their protocol here. And they worked for me and‑‑but I did have a small relapse that put me back, and now I’m in a stringent complete remission situation, which is great.

And I enjoy hearing other people because they help me to understand some of the things that I did experience, and I’m grateful for that. But all those things can change for anybody, and so I thank you for what you’re sharing today.

Cindy Chmielewski:
The one thing about neuropathy I didn’t hear anyone mention was I know sometimes you can dose reduce. You could take maybe a smaller dose. That’s something that you may be able to discuss with your physician if that’s something they’re willing to try. Or sometimes you can take the full dose but spread it out a little bit longer, you know. Instead of twice a week getting a treatment once a week or one every other week.

So I think the important thing is especially with some of these side effects that you experience when you’re taking some of the medications is that open communication with your physician, telling them exactly what is bothering you and how it’s bothering you. Because together you might be able to make some time of decision so that you don’t have to live with the pain, that there might be some way to reduce it or to manage it in the best way possible.

Let’s get into these GI issues and nausea. It sounded like something that people are experiencing. I know the most times I had that was during my stem cell transplant, so why don’t we maybe talk about transplant first and then maybe talking about ongoing and maintenance therapy later on. Ways that you got through your‑‑how many people have had transplant first?

Sarah Frisbie:
Yes, I did.

Cindy Chmielewski:
And Lynne, you had two. Paula, have you had a transplant? Yes. And Jill?

Jill Zitzewitz:
Yes.

Cindy Chmielewski:
And, Steve, did you have a transplant?

Steve Simpson?
(? Inaudible.)

Cindy Chmielewski:
Melissa?

Melissa Vaughn:
I actually‑‑I chose not to do the transplant because I plan on doing IVF, actually‑‑

Cindy Chmielewski:
Okay.

Melissa Vaughn:
So‑‑I plan on having another baby.

Cindy Chmielewski:
That’s important. Actually, that can be something we talk about in a few minutes. Let’s talk about transplant. How did you manage some of those severe side effects that comes with stem cell transplantation?

Steve Simpson:
Some of the what? Could you repeat that?

Cindy Chmielewski:
Some of the severe side effects. You know, I mean, I’m sure you didn’t have any?

Steve Simpson:
You know, that’s kind of weird because transplant, and again, it just goes back to everybody reacts different because this is one of those where you sit in your two‑hour consult meeting and they drill you with everything you’re going to supposedly‑‑you can anticipate, I’ll put it that way. Your time in there, what to expect, this may happen, that may happen.

And I’ll be honest, this is one of the most surreal things I’ve ever seen because the eight or nine hours to take out your own stem cells, that was probably worse than the actual two days of the transplant process because that’s, you know, you’ve got to sit there. You don’t get to go anywhere.

Transplant itself was, I said surreal for me. It was, you know, they come in 24 hours from the time you had the chemo the day before, and had no issues from that. I sat there in total (? Inaudible) for an entire day. They came in and within 12, 15 minutes you’re done. And I looked at my hematologist, I said, really, we’re done? That’s it? He goes, yeah. I said, okay. You know, two and a half, three hours later I’m walking out of the hospital‑‑or out of the cancer center, excuse me, and I never went back until day 98.

So side effect‑wise the worse thing was, what, five days later when your white count goes down to zero and the four buses run you over all at once, you know, you can’t prep for that. So from my standpoint that was probably the worst of it right there, just that normal, okay, you watch your white blood count, have fun now because you’re going to be out of it and go to it. So side effect‑wise I really didn’t have anything.

I was very fortunate through the whole process again, number one, to be able to leave that same day because nothing really changed physically for me at all. I just kind of sat that and I’m like, okay, Dr. Kelly came in I said, okay, can I go home? You know I live 12 minutes, 15 minutes away. I have 24‑hour care if I need it, and everybody in this hospital is what, they’re sick, right? So how about we just go home and we deal with it, and it was fine.

I left, and I felt perfectly fine for the first three or four days like nothing happened, but then once your count drops it’s kind of like, whoa, here we go, but that was about the worst. Other than appetite, but that’s part of the process. So I guess I got lucky from that standpoint. Very lucky.

And that’s where I stress so hard with people that everybody reacts different. Nobody reacts the same, and as we do this and we get on the social media pages of people asking questions they got to understand that everybody is different. And that’s why I like these because you can hear all the different things that go on. Again, I feel very fortunate that I’ve been able to kind of just glide through this whole process with not a lot of issues to deal with, so.

Cindy Chmielewski:
Anyone had like GI issues they had to deal with transplant, fatigue, ways that they (? Inaudible)?

Lynn Worthen:
I learned to pay attention to what the doctors said. They gave me a sheet of paper and they said take these medications in the morning and these in the afternoon and all that, and I looked at it where it said laxatives and stool softeners, and I said I’m not going to become dependent on those things. I’ll make it just fine otherwise. Well, two days later I was asking at 8 p.m. what we could do about the problem I created.

And I learned to pay attention to what they said because I had no background to understand how steroids and chemo‑‑one lady she called it the concrete maker, I mean, how it could really create issues for you. So I learned to pay attention and to know that they’ve been there before and they know a lot more than I do about this sort of thing. And that helped me all the way through.

But, anyway, I just learned to negotiate it by doing exactly what they said about use of laxative, use of stool softener, all that kind of stuff so that you didn’t create a much bigger issue.

Jill Zitzewitz:
I had a lot of problems with nausea, and I found that‑‑I mean, they did give me medication for it, but I really didn’t want to eat anything, and I finally found a couple of foods that appealed to me, canned peaches and yogurt and oatmeal, so that’s all I ate for about 10 days. Literally, that’s all I ate. And then I went through this phase of egg sandwiches when I got home. I just wanted egg sandwiches on toast, you know, fried egg sandwiches. I’m not sure why.

But I didn’t really worry about not getting all of the nutrition I needed just to figure out what I could tolerate, and figuring that out and just going with helped a lot.

And then I also walked every day. When I was in the hospital I forced myself to walk up and down the hallway carrying my IV pole, dancing with my IV. But‑‑and then at home I paced my driveway outside, tried to get a mile in every day, but it would be in like little blocks. Maybe I can do a quarter mile and then after I rested I’d do a little more. And that really helped I think. I got my energy back a lot quicker.

Sarah Frisbie:
I was hoping‑‑I had watched videos and different things of people who had gone through transplants, and I was hoping that I would be one of those people that it wasn’t too big of an issue, so I kind of went into it with a hopeful attitude. But I was really, really sick, and it lasted quite a while. I did it in the‑‑I stayed in the hospital, so I was there maybe I think about two and a half weeks, but it was just‑‑I could barely keep anything down.

But I did eventually‑‑because in order to leave I had to start figuring out how to eat. But I did find some things like you said that I could keep down. And so I developed this love of Wendy’s frosties and I would just eat those. Because I needed calories, you know, and same as you, Jill, I wasn’t worried about nutrition. I just needed to keep something down. So I had frosties for like two weeks I think, pretty much lived on that. But I was‑‑I had so much nausea, and they gave me stuff too for it, but it just seemed like nothing would get rid of it. So that was my experience.

Cindy Chmielewski:
I was more like you, Sarah. I tried to keep on top of it because they told me if I kept on top of it with the medications it was best, but I just couldn’t shake the nausea and the diarrhea every time I ate. And odors were a big thing. There were certain smells that I just couldn’t tolerate just smelling those things. It was strange because some of the things that I’d loved before I had my transplant I couldn’t even stand the odor of.

And you had frosties, I had custard ice cream. That was the thing that got me through, you know, at least being able to eat because I was too in the hospital and they wouldn’t let me out of the hospital until I showed them I was able to eat something. So everyone is so different.

Paula, how was your transplant experience?

Paula Waller:
My transplant was inpatient, and I think nausea was probably the biggest challenge and also mouth sores. Not in my mouth so much but in my throat, and that made eating really difficult. I survived on popsicles for several days.

Cindy Chmielewski:
For mouth sores. Did you do anything else for those mouth sores?

Paula Waller:
The medical team there gave me pain medicine, but basically just had to kind of wait for them to go away. And I did do the ice before the‑and during the melphalan but still got the sores.

Cindy Chmielewski:
Still got the sores even with the ice. For those of you that don’t know, some of the online support communities encourage you to suck on ice and to eat ice the entire time of your melphalan infusion in hopes of not getting the mouth and throat sores. And once again it was something I spoke to my doctor about and he said, can’t hut so if you want to try it give it a try, so, you know, I did. I didn’t get mouth sores, but, Paula, you did, so I guess there is no rhyme or reason for some of the things that we do.

Jill Zitzewitz:
At my hospital they had us eating popsicles because they wanted you swallowing it too to keep your throat cold, and so apparently I almost beat the record. I ate 24 popsicles during that week. But I didn’t have any mouth sores, so it worked for me.

Lynn Worthen:
The nurses told us to eat ice two hours before until two hours afterwards, and being who I am I decided if it worked that way I would just start when I got up in the morning and I would eat it until I went to bed at night, and it worked okay for me. Got water in me and also it kept my mouth and throat cold so I didn’t have problems with it. But I was around people who have had some severe problems like all of you said, and it can’t be a very pleasant experience.

Cindy Chmielewski:
Melissa, would you mind speaking a little bit about your choice of not going for a transplant and why you made that choice?

Melissa Vaughn:
Yeah. So originally when I was first diagnosed we planned to do the transplant and then after four months of treatment my body responded pretty well and then after talking to my oncologist about having another baby because I did‑‑I did IVF prior to treatment because just in case I would need the transplant we decided to do IVF. And after I responded well to treatment I decided‑‑I made the decision with my oncologist to hold off on the transplant so that we could try and have another baby because my IVF was successful, and I knew that it would take a long time for my body to recover after the transplant.

So even if I had just got close to remission the plan was still to hold off on the transplant as of yet. Just because of the current medications that there are I could keep it under control even with steroids. So after seven months of long treatment I did get full remission and so the plan was still to have another baby. Unfortunately, I’ve had some symptoms again, so I don’t know if it was a good decision to hold off on transplant or not, but we’ll see here in the near future, but that was still what I decided to do.

And my hope is still to have another baby. So whether I have to go back on treatment for a little while or if I have to keep it under control with steroids. Of course while I’m still having bone pain and things like that, especially in my pelvis, I don’t know want to have a baby and have a pregnancy with that added pressure on my pelvis. So we’ll just see what the future holds. But that was my decision, that was my reason why (? Inaudible).

Cindy Chmielewski:
And a good reasoning, and best of luck to you. I do know another very young myeloma patient who had one child and now is pregnant with her second child so, you know.

Melissa Vaughn:
I have a three‑year‑old little, boy so I’m hoping to give him a sibling.

Cindy Chmielewski:
Great. Wonderful. Okay. So now that we’re over our little transplant, how about some of the side effects you have (? Inaudible) treatment or maintenance therapy? Someone? Okay.

Off Camera:
One second. Could you just repeat that, Cindy?

Cindy Chmielewski:
Okay. Was that you, Ruthie? No, it was just somebody’s phone went off or whatever, but we can just restate the question and try (? Inaudible).

Cindy Chmielewski:
Okay. Now that we’ve gone over some of the side effects and how to manage them through‑‑let’s try that one more time. See, this is its chemo brain that kicks in. I’m in the middle of a sentence and I forget what I’m saying.

So now that we’ve discussed some of the side effects we were experiencing through our stem cell transplant and how we went ahead and managed them, now that our transplants are over and right now I guess maybe some of us are doing some continuous therapies, some of us are in maintenance therapy. Are your side effects as severe? Are they any less? Any tips, any discussion?

Jill Zitzewitz:
So I am now doing maintenance therapy with Revlimid, and I’m having the same kind of issues with the rashes and my skin is just‑‑I don’t know if it’s partly post transplant as well, your skin is just kind of not the same or if I’m just‑‑that’s where I get lots of problems. So I’m still trying to manage that by modifying the dose. You know, instead of going 21 days and then a week off we’re trying two weeks on, two weeks off. We keep dropping the dose to see, and it’s getting better.

And so I think what you mentioned earlier about working with dosages to try and help, that same thing happened to me during induction therapy with Velcade. I got a terrible rash, went to a dermatologist, and he said, well, I’ll give you an EpiPen just in case, but you need the drug, so. And‑‑but we were able to modify it by modifying my schedule of when I got the dex. I got some of it after my Velcade shot and not all of it before, and doing it once a week instead of twice a week without taking a week off, but there were ways to kind of modify the dosage to deal with the skin issues that I’m having.

Cindy Chmielewski:
Were there any ways you treated the skin issues besides‑‑

Jill Zitzewitz:
Oh, yeah. So there was sort of like a steroid cream on my skin to try to help with that. I found that especially post transplant if my skin gets dry at all or if I get in the sun at all then things get worse, so I’m pretty religious about Eucerin skin calming lotion to keep my skin moist and definitely using steroid creams when things flare up.

And also I’m trying to work on diet to see if that can help, if maybe, you know, maybe I’m already a little bit sort of‑‑my immune system is a little out of whack and I’m taking an immunomodulator which is partly throwing it out of whack a little more. So I’m trying to like limit dairy and gluten and things like that to see if it has an effect, but I don’t know yet.

Cindy Chmielewski:
Okay. Anybody else had to deal with skin issues or rashes?

Steve Simpson:
Kind of an interesting thing because coming out of a transplant obviously you didn’t pick up any Revlimid until after the 100 days or whatever, and I was still back on the original 25 milligrams, and as soon as we started that back up the rash, literally it just took off and it was just‑‑it was brutal. But the oddball thing is we did drop Revlimid down and right now we’re at 10 milligrams, but the steroids I take on Sunday are also for the purpose of keeping that rash down and nothing else. That’s the only reason I went onto that was simple for that purpose, and it’s worked fine since then. We’ve dropped that steroid down to maybe, probably eight milligrams a pop because instead of 20 on any given Sunday I take just eight, and that part helps the neuropathy but it’s also kept the rash down.

Now, could I stop that entirely? I don’t know. I might be able to, but obviously the rash wasn’t as severe as some of the other people have, but that was‑‑that was the hematologist’s decision to try that steroid because at the point nothing else was working anyway, so that was kind of a (? Inaudible) that worked so, but, you know, it’s been fine since, so.

Jill Zitzewitz:
Another thing that I heard at Dana‑Farber and I’ve heard a lot of other people that said this, either Claritin or Zofran or some 24‑hour antihistamine type for allergy medicine, and I’ve been taking Claritin, and that actually seemed to have helped too.

Cindy Chmielewski:
With the rash? Okay.

Paula Waller:
I took Claritin also. I had a rash just a couple of times during induction and either the rash was self-limiting or the Claritin really did help.

Cindy Chmielewski:
Good. How about fatigue? Anybody have ways that they manage fatigue or help (? Inaudible) fatigue?

Steve Simpson:
Kind of a weird one. Everybody again being fatigued comes and goes, and for me I guess it’s more or less how much I’ve done during the day. Again I’m‑‑before this all started I was a hyperfit individual, 52, six days a week in the gym or whatever and, of course you can’t give that up, and that’s been a struggle. I’m finally back in at about that pace. That will fatigue me out. And to be honest with you for me now I haven’t been back to work, started, so we’re going on close to three years now. I’m trying to get back, but I guess the only way I can say this is you learn to listen to your body maybe a little better than you did before. I’m always 110 percent, 110 miles an hour, it’s just how I’m wired, and you can’t do that anymore, so now you start feeling that fatigue point, you almost got to just cave in and take a break.

I’m not a person to take naps in the afternoon unless it’s one of those things where like over the recent past I can’t control it, but just got to learn to listen to yourself. If it’s time to take a break, you take a break. I don’t know what else to say because sleeping on a regular schedule is virtually impossible. It doesn’t happen anymore. I hope someday it does, but even with a CPAP I’m lucky to get five, six hours at best in a given night. And of course steroid days forget it. You’re lucky to get two or three over the course of a couple days.

But for me again it’s just listen to what your body is telling you, and if it’s telling you better slow down, slow down. Because again if you don’t, we all know that that’s going to get you in the end, the stress, the fatigue. There are so many things that we don’t‑‑we didn’t focus on prior, at least I didn’t, they’ve now become a point to where if you don’t you’re going to get sick. And obviously we all know that getting sick is the last thing we want because that just multiplies to something we don’t want to deal with. So it’s just kind of one of those things.

But exercise I think is one of those that for me kind of helps with that because you start pushing yourself, you build the endurance, build that ability to do a few more things or more than you maybe were doing before. It’s the same thing as after transplant, get out and walk, get out and move. I can remember after transplant if I was lucky to get two or three block is in on a walk that was good at the time, but at least it was something. You know, you had to build that stamina, you had to build that part of it back up. It’s a continual process. You’ve got to keep going.

Cindy Chmielewski:
Right. So listening to your body, taking a break when you need to. I think that’s great advice. Building up your stamina with a little bit of exercise at a time. Anybody else, ways of dealing with fatigue?

Melissa Vaughn:
As a therapist for a long time and actually working with patients it was interesting to be a patient myself, an interesting experience. And something that I’d always counsel patients to do was to exercise and to eat right. And before my multiple myeloma, before I was diagnosed that’s what I did, and even back then it had an impact on how my quality of life was. And even as a multiple myeloma patient I realized how important those two things really are even as a patient and how I had to kind of eat my own words and really battle through the fatigue because that was probably one of my number one and most difficult symptoms was fatigue. And so even though I didn’t feel like it many days, just getting up and walking.

And also I’ll put in a plug for physical therapy because that’s the realm I work in, and they work closely with your doctor, and they can devise a treatment plan based on your precautions, contraindications, things like that of that nature where you can exercise safely, and they can develop a treatment plan for you. They can also issue braces and things like that if that’s what you need to exercise. But I truly believe that that can increase your quality of life, those two things. Post transplant, pretransplant, during multiple myeloma.

Cindy Chmielewski:
I agree. Unfortunately, I was not one of those most fit people like Steve was prior to my transplant, prior to my diagnosis, but I now know that whenever I’m starting to battle fatigue or not feeling right I go back and I look at what I was eating, if I’m not doing any exercise, and that usually correlates with it. Even if I just get up and go outside, take a walk, being outside in that fresh air, maybe doing some mindfulness out there, enjoying nature, just trying to get my mind off maybe all those stresses because stress sometimes causes that fatigue too, you know. And eating right, eating food that provides you with energy, you know, I think those two are really good points in dealing with fatigue. Any other?

Jill Zitzewitz:
Related to exercise, so I did do physical therapy before I was diagnosed because of the compression fractures, and that definitely helped with building my core strength, and I kind of kept resorting to those exercises during the transplant process. But I was a little bit nervous about exercising vigorously because I didn’t know how strong my bones were, I was afraid of‑‑and so I actually joined the Livestrong program at the YMCA and I found that to be incredibly‑‑I mean, I’m doing Zumba and things I wouldn’t have done before. A lot more cardio, because you can do it in a modified way. They can work with you, we do it‑‑and I learned how to do yoga, I learned how to trust my body more and take breaks when I need to, not to overdo it, you know, to set my own limits.

So I found that that was really helpful for me. It was also a support. There were other cancer survivors there, and it got me back exercising, and now I’m also back in the lab. I’m a scientist, so I’m on my feet most of the day in the lab, but it actually helps. It doesn’t make me more tired. It helps me to keep moving.

Cindy Chmielewski:
I agree. I was part of the Livestrong at the Y program, and it really did help because you have the one‑on‑one trainer to help modify those exercises just for you. So I felt more comfortable than just joining a gym. And, like Melissa said, I went to physical therapy because I wanted to start exercising but I was afraid because I had so many compression fractures. What I should be doing, you know. I didn’t want to hurt myself anymore. I lost three and a half inches in height throughout this process, you know, and when I went to the physical therapy fortunately we were able to do like aqua therapy in a pool and learning how to do Zumba in the pool and just many resistance exercises, so I didn’t have all that stress on the body.

And from the physical therapy I was able then to join the local pool and take part in some of those classes that weren’t putting the stress on my bones in the very beginning (? Inaudible). I agree physical therapy could really help with getting to exercise, and then once you start exercising you might gain some more energy and the fatigue may go away. Anyone else? Okay.

Let’s talk about online patients communities. Any of you belong to any of the online patient, either Facebook groups, Smart Patients, PatientsLikeMe? Any of those?

Jill Zitzewitz:
So I’ve joined some of the online Facebook groups, but I actually didn’t when I was first diagnosed. I think I was a little overwhelmed and I didn’t necessarily want to hear everybody’s stories, but now that I’m feeling better I feel a little bit more like maybe I can offer some support. So I found them to be very helpful, things that you might not have even thought of, thing that you can bring up to your doctor come up, right, because people have different experiences.

I was kind of afraid to be on the web too much because there’s a lot of things out there that you don’t know how helpful they are and they can be scary. I have four kids, and first thing they did, they’re teenagers, was go on the web and think oh, no, mom’s got three to five years to live. She’s not going to see me graduate. She’s not going to see me, you know, get married or have children, and that’s not necessarily the reality for myeloma patients today, right?

So I think finding good resources and finding support and hearing the stories of survivors who have been, you know, 15, years, 20 years at it, you know. It’s starting to become very encouraging I think for everybody.

Cindy Chmielewski:
Anyone else on any of the online communities?

Sarah Frisbie:
I am on Facebook. I have‑‑and I look at it. I’m just the opposite of you, Jill, because you said like when you were not feeling well you didn’t, you know, you didn’t want to hear like any scary stories, and when I was feeling good I didn’t want to think about it. And then if something would happen or I’d relapse, then that’s when I guess I was wanting to hear what other people did. But I agree it’s very encouraging to hear people who have been successfully either in remission or at a low level for years and years. That’s probably the most encouraging thing, I think.

Melissa Vaughn:
I think I’m the only one on Instagram. There’s not a huge myeloma community there. However I did put myself, I tagged myself as myeloma in there, so I have connected with a lot of people actually a that have‑‑it’s a little more difficult when you’re‑‑I have to say when you’re younger because there’s not a lot of people with young kids with multiple myeloma or want to have another baby? (? Inaudible).

Cindy Chmielewski:
Right.

Melissa Vaughn:
(? Inaudible) connect with other young people and so a lot of people, yeah. That helps to connect (? Inaudible).

Jill Zitzewitz:
There is a Facebook group for myeloma patients who are under 50. They let me join even though I was 53 because I am a working mom with four teenagers, (? Inaudible) relatable. And I found that one to be‑‑

Melissa Vaughn:
Very inspiring.

Cindy Chmielewski:
Yeah. And actually I was talking to someone in that Facebook group and he is in his 20s, so I think he is trying to start a Facebook group for myeloma patients who are maybe under 40, so there might be a totally different perspective even having more children. I’m on Instagram too, so I’m going to have to find you.

Melissa Vaughn:
Yeah, it’s myelomamama. That’s what I call myself.

Cindy Chmielewski:
Oh, I do follow you. I’m myelomateacher on Instagram so I’ll follow myelomamama. Okay

Melissa Vaughn:
(? Inaudible) so I know you.

Cindy Chmielewski:
What? I’m having a hard time hearing you, Melissa.

Melissa Vaughn:
Oh, sorry. I don’t know if my internet connection is kind of going in and out. I just said okay, I do know you. That’s what I said.

Cindy Chmielewski:
Cool. I think I was more like Sarah with online communities. When I first got my diagnosis was 10 years ago. It was prior to most of the Facebook communities there, and Smart Patients was at that time called ACOR, (? Inaudible) cancer online resources, so it was a long time ago, but I knew nothing about myeloma. I was really an uneducated patient. I really didn’t know much about what types of questions I should be asking my doctor or any conversation. So just being part of that community and working and seeing what people were talking about in that community, I would just write down questions that maybe I should be asking my doctor and, you know, or things that other people were doing to see if that was something I should consider doing.

So for me the online communities really helped first educate me as a patient to learn what I should be doing at a patient, how I should be engaging with doctors because prior to that I was brought up in that age of doctor knows best, and I just blindly followed whatever the doctor was telling me, and I soon learned that conversation was something that was important, but then also when different things were coming up I always had my list of questions that I wanted to ask if this was okay for me to do too, so. Anyone else on any of the communities online?

Lynn Worthen:
I’m not on online communities, but I just want to put in a pitch for any kind of communication between patients. That’s particularly what I do when I go and speak to support groups, but I’ve watched the ability and the power of groups to help someone who is really struggling with some of the decisions about treatments and that sort of thing. If they can talk to someone else who has been on that journey already, it can make a lot of difference.

I’m thinking particularly of a group in Boca Raton, Florida, where one man was going to do nothing. He was as low as a snake’s belly in his depression. And I watched that group who knew him talk to him and the lady who led the group texted me a few days later and said he’s decided to go and be evaluated. You know, it was the power of that group to help that person make good decisions about their life. So things like this where people can talk to each other I think are really very, very good.

Cindy Chmielewski:
You bring up a good point. Any type of group, online, in‑person. There’s a number of myeloma support groups across the country that if you’re fortunate enough to be in one of those cities could really help you out. Could pick you up, could provide you with lots of information. So, yes, definitely the power of the groups. Okay.

Any other words of advice, anything else we didn’t talk about you think it’s really important for someone maybe even newly diagnosed with myeloma should know, should think about, should explore?

Steve Simpson:
I’m going to bring this up. The biggest thing that we pushed is that we, my wife and I, have I guess pushed ourselves as advocating for yourself, and I’m going to say that because again being on social pages and reading, there’s a lot of people out there that don’t realize that they can advocate for themselves in more than just your own health. My perspective on this was you went in to a visit, like when I go see a hematologist, if I walk out with a question unanswered that’s my fault. That’s not his, that’s mine.

We have a very busy cancer facility where I’m at, so these guys see a high number of patients every day and they’re busy, but they take the time that they need. My visits can go anywhere from five minutes, 10 minutes to maybe 20 depending on what I have going on. I’m usually the short version of a visit. They like that. I’m in and I’m out, everybody’s happy. But you have to advocate for yourself.

And the biggest thing that came about for this with us is when it came time for the stem cell transplant the insurance that we had at the time told us that you are not going to have it here at Avera in Sioux Falls because they were now what they call a center of excellence, which is a piece of paper. I could go to Omaha, I could go to Mayo, I could go to the U of M. I said no, no, and no. Now, the lady who was dealing with this was in Florida, so she had no idea not only where I was at but didn’t even know really what was around there.

So on call number one we got a little vocal with her and said okay, take your hands off the key board, listen very carefully. I’m going to tell you where I’m at. I’m going to tell you my four options, and then as we went on it went down to where they’d only cover certain percentage of the transplant, then all of a sudden I was told if I was going to stay here they wouldn’t cover any of it. And I said, well, guess what we’re going to do. We’re going to stay here.

So we spent two and a half months between myself, my advocates in my cancer center and my hematologist dealing with these people at the insurance company saying, look, there’s a reason we’re doing here and here are the reasons. And after two and a half months and delaying the transplant I think two weeks I stayed here. I didn’t have to go anywhere.

Now, you get into this issue of money and all these things with insurance obviously that comes with all of this, but in the long run I didn’t stay in the hospital. I went home, so I look at it as I just saved you guys some money because I was in there for the day and a half and out of door and gone. So had I been somewhere else I would have had to stay there, and that wasn’t going to happen. I had parents who at the time were 81. They can’t travel. We have kids. My wife has to work. She can’t travel. So you lose your support group.

You now go to a different doctor who doesn’t know you. He doesn’t know you from myself knowing any one of you guys stepping up saying hi, how are you other than having pieces of paper in front of you, so you’re basically starting over. I told him I would not do that. I did not just spend all these months going back and forth every day to have you tell me I have to start over just for this process. I said that’s not going to happen.

So that advocating for yourself becomes a really big part of this process. And there are a lot of people who I don’t think understand that, that you can do this. And there’s nothing wrong with doing it. Don’t stand there and let them say you have to do it this way because you don’t. Push yourself and push them to realize that this is about you. This is your life, this is your future, this is your family’s future, and anybody else you have as caretakers, caregivers, whatever you want to call them, this is what you guys have to deal with. So we pushed and we pushed hard, and we’ve always done that and we will continue to do that. And you know, that was‑‑that was stressful when you get to that point. It’s not any fun doing it, but you have to do it. That’s just the bottom line.

Cindy Chmielewski:
Have to learn how to become your own best advocate. Some of us know how to do it in the beginning and some of us need to learn, but you do need to be your own best advocate.

Steve Simpson:
Right. And we’re fortunate because we have advocates for about everything in our (? camp). We have advocates for the insurance. We have advocates for the LLS and all of these little things you can get. We have people that do all that for us, but you still have to be there for yourself and you still have to voice yourself and just voice your opinion and not be afraid to do that because nobody’s going to yell at you for it, but you’ve got to be able to do that.

Cindy Chmielewski:
Exactly. That was one thing I learned, that no one will yell at me for saying my opinion. That was what was I was afraid of, that if I disagreed with someone they won’t like me or they won’t take care of me the way I should be taken care of, and I learned that that was wrong, that I needed to advocate for myself. And people actually respected me when I started advocating for myself and kept becoming that empowered patient. So that was a long way for me, but I agree. You do need to do that day in and day out.

So final words of wisdom. Everyone think of something final to say and words of wisdom to the people who are going to be watching this video.

Lynn Worthen:
None of us picked having myeloma. We didn’t choose that, but we can choose how he handle it mentally, our attitude about it, all those kind of things. And it is very, very important to have as positive an attitude every day as do. Sometimes it’s hard because this stuff can drag up into a dark hole, but whatever it takes to keep your spirits up and to be positive about things will help a great deal even in the treatment process.

Cindy Chmielewski:
Good.

Sarah Frisbie:
I think, and someone mentioned this or maybe more than one person mentioned this before, but the idea that if you are having severe side effects or even just moderate ones talking to your doctor about maybe tweaking like how much or often the scheduling of your medicine because that’s helped me too in the past.

Cindy Chmielewski:
Anyone else have some final words?

Jill Zitzewitz:
I would just say find your community. Don’t try to walk this journey alone. For me I think that was a huge part of it. It was hard to say yes to the meals that people wanted to provide or to help with the kids, but be willing to accept people’s help and don’t try to walk it alone and just rely on people around you to help care for you when you need that.

Cindy Chmielewski:
Paula?

Paula Waller:
I agree completely about maintaining a positive attitude and outlook, but I would say see a specialist. I think every myeloma patient should see a myeloma specialist. Advances are being made so quickly that I think that’s the best way to keep up with it and to make sure that you get the best treatment.

Cindy Chmielewski:
And Paula, just a follow‑up question, for someone who might not know what a myeloma specialist is, what do you look into to make sure that the person you’re seeing is a myeloma specialist?

Paula Waller:
A myeloma specialist who would be a physician who treats just strictly myeloma patients or myeloma patients and other patients with very closely related blood cancers.

Cindy Chmielewski:
Okay. Good. Melissa, do you have any final words?

Melissa Vaughn:
Well, I concur with everybody what they’ve said. I would just say just don’t give up. Like it’s going to be okay. Like multiple myeloma, even though I’m young, it was not the end of the world. I still have a long life ahead of me, and there’s a lot of treatments on the horizon. There’s a lot of information out there, and you’ll grow into it. It was a little overwhelming at first and that can’t be helped. You’re going to feel those feelings of sadness, and it’s a grieving process, but you’ll be okay.

Cindy Chmielewski:
Good. Steven.

Steve Simpson:
I’m going to go back to what Lynn said, nobody asked for this, you know we didn’t, and it doesn’t do any good I guess to sit and wonder what caused it either because I know if anybody’s on those pages you get all those conversations, well, I did this, does this cause it? No, not necessarily, it happens and that’s just part of life. Now, from my standpoint my whole goal from the beginning was to get to a point where you wouldn’t know you had anything at all, you weren’t sick. It’s a struggle in the beginning. It was for me because I had lost so much weight and I came out basically skin and bones from the surgery and everything else.

It was a long haul after that surgery because after you have, you know, that nice 10‑inch opening down your back and you’ve got 45 grand of hardware in your back, I spent probably two‑plus months where I couldn’t even take care of myself. It was complete 24‑hour care with everybody else because if I tried to stand up and walk the left side was completely paralyzed so I couldn’t even hardly do anything. That was from the nerve damage, and when they rip it open to repair all those‑‑the pins, the screws, the rods, all that stuff causes wear and tear on the body. But from my standpoint it was okay.

As I told Kelly, your job is to do this, my job going to be to do this, and you do yours and I’ll do mine. And that’s kind of where I took it. I said, you know, I’ll do what you guys tell me to do knowing that we’re going to talk about medications and stuff like that, but I’m going to do everything in my power to get myself back to where I need to be to where things are basically more normal wherever that new normal might be. And that was just my push was that attitude where, okay, I’m going to go back to where I was or as close as I can get to where it was. And it if it takes an extended period of time, which it does, so be it, but you just have to keep yourself moving.

You know, I agree that the negative attitude doesn’t really‑‑doesn’t do anybody any good in regular life let alone now when you got all these things going on because again you never know what’s going to show up the next day. That’s the joy of this, I guess. We can all be sitting here happy today and tomorrow three of us may be out cold because we can’t stay awake. We don’t know.

It’s just an unknown, so you learn to take things in stride. I learn to take side effects to where unless it’s at a point where I just don’t like it or I can’t handle it I don’t even bring it up half the time anymore, and they know that. If we don’t bring it up in a conversation in a visit we’re not going to deal with it. Only going to deal with it once I ask for it because I try to manage a lot of that on my own. I don’t know about the rest of you but I was‑‑growing up out here in the Midwest in this lovely great white north as I call it you learn to have your body take care of a lot of the issues on your own. If you got sick, your body took care of it for you. I was fortunate as a kid if you got sick or you didn’t get sick your body was able to take care of it. Well, guess what, that doesn’t happen anymore. But you still try to find that diet or that exercise, all those things that aid in that part of it.

But it’s just that attitude you take coming in and try to keep it going forward. And a big part of that is the support groups we have, you know, the families or people you can talk to. All those things kind of come into play, so.

Cindy Chmielewski:
Thank you. And I guess my final words of wisdom being a former fifth‑grade teacher and myelomateacher on the internet I think it’s so important to educate yourself, you know. I believe knowledge is power, and if you’re an empowered patient having discussions with your doctors and with your care team no matter what, I think you’re going to have the best possible outcomes for your situations. So educate yourself and find support, and just like Steve was saying make sure your voice is heard.

I want to thank you all for spending time today, sharing your knowledge with us and hopefully inspiring some others.

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