Seeking out a 2nd and 3rd opinion in her cancer treatment resulted in a dramatic improvement in Sasha Denisova’s quality of life.
Sasha first appeared on this podcast in Episode 83 where she shared the struggle she faced getting doctors to take her colorectal cancer symptoms seriously.
During our latest conversation she discussed why she made the decision to forego treatment at the Mayo Clinic in Minnesota to seek treatment at Memorial Sloan Kettering in New York City. We also discussed:
How she got the courage to challenge the initial treatment recommendations made by her doctor and why it’s important for everyone to advocate for their best care.
The importance 0f seeking out opinions from the top rated cancer facilities in the U.S.
How she eased herself back into working out in the gym and why working with a guided fitness instructor was important.
Why exercise is vital to her well-being and how most cancer patients can find an exercise routine that works for them.
https://powerfulpatients.org/pen/wp-content/uploads/Podcast-3.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-09-09 17:24:392019-09-09 17:24:39Why Getting a 2nd and 3rd Opinion Made a Difference In Her Cancer Treatment, With Sasha Denisova
This podcast was originally publish on NPR by John Henning Schumann, Mara Gordon, and Chloee Weiner on September 7, 2019 here.
Finding out you have a serious medical condition can leave you reeling. These strategies from medical and lay experts will help you be in control as you navigate our complex health care system and get the best possible care.
Here’s what to remember:
1. Your primary care doctor is the captain of your health care team.
With any serious diagnosis, there will usually be more specialists to see. Having a primary care doctor you trust helps coordinate the information flow and keep track of the big picture. Your primary is on her toes for possible medication interactions. Regular preventive measures shouldn’t be overlooked, either.
2. Don’t be afraid to get a second opinion.
If you’re offered treatment such as chemotherapy or surgery that can be life-altering, it’s crucial to get more than one opinion, ideally from a doctor working for a different institution. Oncologists and surgeons expect patients to seek second opinions — many provide them as a major part of their practice. If your doctor resents you seeking more opinions, that’s a red flag.
3. Get organized, stay organized, and find someone to help you if you can’t do it yourself.
Make a list of what you hope to accomplish at the doctor’s office. If for some reason you aren’t able to take notes, bring someone along who can act as an advocate and make sure your concerns aren’t overlooked. Ask for copies of your medical chart and test results so that you are part of the conversation — you have a legal right to see your records.
4. If you need a procedure, go to someone who does it all the time.
It’s true for medical care as it is in life: The more a doctor does a procedure, the better at it she’ll be. This means fewer complications and better outcomes. It’s OK to ask your doctor how many times she’s done a procedure; a high volume means competence when things go as planned, and calmness for unforeseen complications.
6. Figure out what matters to you, and fight for it
Our default setting for health care is that more testing is always good. But that’s often not the case, as tests have side effects and can cause undue anxiety because of false positives or incidental findings. Have a frank conversation with your doctor about your values and what you want (and don’t want!) and you’ll be an empowered patient with a doctor as your advocate, not your adversary.
https://powerfulpatients.org/pen/wp-content/uploads/Podcast-2.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-09-09 17:18:422019-09-13 16:49:42Take Control Of Your Care When You're Seriously Sick via NPR
https://powerfulpatients.org/pen/wp-content/uploads/Podcast.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-09-09 17:10:102019-09-09 17:10:10Learning How to Simplify Cancer With Joe Bakhmoutski
A dad I know recently posted a photo and shared his excitement on Twitter about a new set up for his bike with a trailer for his son. Its overall purpose being an opportunity to do more stuff together as a family. I wholeheartedly shared in his excitement as I too had been putting money aside to find more opportunities for my own family to get outdoors more. Both of us are parents of children who were born with a rare diagnosis. Our kids have different rare diagnoses, but like all families we are eager to connect with the greater world around us and share it with our kids however we can.
My own kiddo is going to be thirteen this year, and we are at a turning point in the discussion of overall health. We are off-book and off script as there’s nothing that clinically describes this age range for his specific diagnosis. Anecdotally, he seems to be following his own trajectory for some inexplicable reason deviating from other children I know with this diagnosis. I’m at the hospital more professionally than I am as mom of a patient which to some audiences the reaction is, “Yay! Your family gets a break! So everything is fine now, right?”. The reaction from fellow parents of palliative patients is, “I’m so sorry”, because they realize the fight is over. That life is going to do whatever it is its going to do. The hospital is still there if you need them, but your frequent family vacation time at “Club Med” is to be replaced with a new family dynamic and new identity as take a go at life more on your own.
Health care is quickly deviating from textbook, generalized care to something highly individualized. This in theory is a great concept but is extraordinarily multifaceted in its impact on patients affected by rare disease. As someone who manages a support group of over 800 patients and caregivers from my home province, I find a deep desire to ask in some capacity whether we are prepared for the pace of advancement. A long-term goal I have in mind is to create a biopsychosocial assessment of the needs of families. For now, I can say for as much new information as I bring to the proverbial table, it’s so often met with, “How do I fit this into my complex world?”.
I hesitate to use the term ‘finding balance’ at all, because if there’s one thing I think many of us rare patients and families experience is more of a need to manage random health chaos. The status of my own family can shift on a dime and you have to learn to be very much ok with that because you have no other choice than to.
So how does one even begin to manage understanding how to frame your life and all the decisions you have to make? For a little over four years, I’ve been working as a parent researcher and engagement facilitator with a focus on the subject of childhood disability. One concept we often speak on is the World Health Organization’s International Classification of Functioning, Disability Health. A simplified version of a very technical document is called “The F Words in Childhood Disability”. Now these are concepts that I wish to argue merit for as a way to create form to thoughts and efforts that you are probably doing already. At the same time, it can become very validating and empowering to realize that current evidence points to the fact that you are already on the right track. These are ideas upon which a potential framework can be created in your own mind as to goals that can be accomplished, or a way to weigh decisions that need to be made. We are often so focused on the burdens of disease, that we need a compass of sorts to point us back to the idea that life is happening around us and time can often be a precious commodity. They are six words that reflect the story that’s unique to you or your family and nobody else.
There is often a need to perform tasks in ways unique to their own abilities. If independence in some areas can be fostered, we need to be able to honor that.
Family isn’t always about people you are genetically related to. People react to the idea of illness very differently and in some cases, you need to seek community and “family” elsewhere. Regardless, the people in your life that you surround yourself with are people that are important to you. It’s important to listen to them as they know you best.
As a post-cancer “spoonie” myself, I often bristle a bit on this subject. Between my own struggles with energy and the physical impact of caregiving, I’ve found it difficult to find the energy to be healthy. However, your story isn’t my story and in reality it can be intensely difficult to find ways to be healthy. In the area of rare disease, I think health becomes a broader term by definition: overall health takes on many forms be it mental or physical health. We often term health as some sort of fitness guru Instagram aspiration, but sometimes overall improved health comes from even the tiniest of steps and even the little efforts deserve to be celebrated in a huge fashion.
Existing around peers can take on many forms, and in order to do so sometimes we need to be brave and reach out to others for more accessible ways to connect with friends. What can’t be ignored is a human being’s overall need to connect with other people as we learn and grow together.
In a world that can be taken up so much with appointments and treatments, its so important to stop every now and then and have fun, be silly, briefly escape the world and just plain live. Fun can take on so many different things.
So much definition of future is often left to the financial planners of the world in regards to careers, academics and whatnot. Sometimes the future is only planning ahead 15 minutes at a time or a week from now. As hokey as it sounds, with age I’ve begun to see the value and emotional weight the phrase “one day at a time” holds in my life. I’ve been asked more times than I can count as to how I picture my family’s future. My response remains that I really am not gifted with that luxury, ask me what I’m working on for tomorrow.
I have seen these terms be threaded through my life in so many ways. Sometimes you are only focusing on one F word at a time and there’s no judgement in that at all. I like any other mom am someone who struggles with whether or not I’m doing a good job. I think the gauge by which I measure this is probably unique to my own personal story but I know that I am not alone in this feeling. I feel though with the F words, I have a more confident platform to stand on not to be his voice but to be his microphone. There’s so much I can’t control in life but as his mom I want to help him own every second as his life to live. So in celebration of birthday number 13, we’re taking “fun” as our next goal and bought a bike trailer too! I know he’ll love it.
Rachel Martens is a mom of a child with a rare diagnosis. She’s one with many hats in the health world in policy development, research partnership, mentorship and science communication. She’s an aspiring runner, crochet fan and enthusiastic coffee drinker.
https://powerfulpatients.org/pen/wp-content/uploads/F-Words-in-Rare-Disease.png600600Rachel Martenshttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngRachel Martens2019-06-17 12:05:192019-09-02 12:28:53F Words in Rare Disease
One piece of advice I give patients who are just diagnosed with cancer – and we do frequently see patients at least once a week who were just diagnosed either that week or the week prior – is feel what you need to feel. Not every patient is going to react or cope with their diagnosis in the same way as someone next to them, even within the same family. That also goes for caregivers and relatives.
So, just because you feel like helping out a relative in a specific way, it might not be the same for your brother or sister or cousin.
So, we always tell patients that there is no wrong or right way to cope with a diagnosis of cancer. The way that you approach it is perfectly fine and there’s no right or wrong way to do that.
So, another piece of advice we always tell patients is don’t be scared to lean on your support network, whether that be family or friends, your healthcare provider, advocacy groups, never be afraid to ask for help.
And for some patients who feel like they have limited resources, usually hospitals where you’re receiving your patient care has many resources available to you, whether that be emotional, financial, spiritual, logistical. Don’t be scared to ask about those resources.
https://powerfulpatients.org/pen/wp-content/uploads/advice.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-06-12 16:22:532019-09-02 12:32:10Facing a Cancer Diagnosis: Advice From An Expert
https://powerfulpatients.org/pen/wp-content/uploads/Untitled-design-24.png600600PEN Editorial Staffhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngPEN Editorial Staff2019-02-19 20:41:412019-09-02 12:32:06Barby Ingle - What Advice Do You Have For Someone Who Is Newly Diagnosed?
A second opinion is crucial to prevent misdiagnosis or unnecessary procedures or surgeries. A study done by Mayo Clinic showed that as many as 88% of patients who get a second opinion go home with a new or refined diagnosis. That shows that only 12% of patients receive confirmation that their original diagnosis was complete and correct. Still, a lot of patients never get second opinions. So, we wanted to chat about this and see what the Empowered #patientchat community had to say, and these were the main takeaways:
The Top Tweets…
https://powerfulpatients.org/pen/wp-content/uploads/Finding-You-Voice-patientchat-Highlights.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2019-02-01 16:44:322019-09-02 12:32:05Finding Your Voice #patientchat Highlights
It’s not easy hearing your name and [insert dread diagnosis here]. I know this only too well after having to find the funny in my own journey through cancer. Cancer is, however, most often a diagnosis that you fight to a defined end. What’s it like to find the funny in a chronic condition like multiple sclerosis, or HIV, or diabetes?
I have a number of friends dealing with the life-long aftermath of an MS diagnosis. One of them tipped me off to Jim Sweeney several years ago. Jim’s MS journey started with vision problems in 1985, he was officially diagnosed in 1990, and has been wrestling with the impact of that diagnosis – finding the funny most of the time – ever since. Jim’s body of work includes decades of live improv, and his one-man show “My MS & Me,” which you can hear on the BBC Radio 1 site. His MS has progressed to the point that he’s now in a wheelchair, and his public presence is mostly limited to Twitter, where his profile says he “can’t complain but sometimes do,” and YouTube.
Some other sterling examples of funny-or-die in managing chronic disease are Mark S. King’s fabulously funny My Fabulous Disease blog. Mark is HIV+, so he shares information, resources, and myth-busting about all things HIV in his posts and videos. He’s brutally honest about pretty much everything, with plenty of humor to soften the impact of what it’s really like to live with what anti-retroviral treatments have made a chronic illness, not the death sentence it too often was in the first two decades after the viral epidemic started in 1980.
Then there’s the “laugh out loud at the absurdity” Six Until Me site from Kerri Marrone Sparling, who writes about her life as a Type 1 diabetic. She covers everything from exceedingly random TSA security agent behavior when confronted with diabetes-related medical devices, to “pregnant while diabetic” to dealing with the emotional impact of living with a busted pancreas, all with a good dose of highly-readable snark.
How much courage does it take to laugh out loud, in public, at an incurable disease? Jim, and Mark, and Kerri certainly have courage – and comedy chops! – at the level required.
On the provider side, there are a number of docs who are breaking up the waiting rooms and wards.
The most visible of these comedic clinicians is Dr. Zubin Damania, a/k/a ZDoggMD – “Slightly Funnier Than Placebo” was his tagline for years, before he shifted to “The Voice of Health 3.0.” ZDogg is a hospital medicine specialist who’s built an empire of snark over the last decade plus, some G-rated and some most definitely NSFW. His videos alone guarantee hours of laughter, and he’s one of the best users of Facebook Live around.
I’ve even found a scholarly article entitled The Use of Humor to Promote Patient Centered Care – be warned, though, that (1) it’s a “scholarly article,” meaning that it’s had all the laughs surgically removed and (2) they want $42.50 for it. You have been warned.
What’s my point here? I actually have two:
1. Laughter really is the best medicine.
Humor keeps us in touch with our humanity, and – unless it’s insult comedy, which I do not recommend in the health care arena, unless it’s insulting bad health care – it helps to comfort others in the same situation.
2. Patients and providers need to work together to help each other find the funny.
If you’re a doctor, don’t just say “you’ve got [insert dread diagnosis here], here’s the treatment plan, call if you have any questions, … NEXT!” Look your patients in the eye, and channel your inner comedian whenever it’s appropriate. If you’re a patient, connect with other people in your situation and see how they’re finding the funny. And help your doctors find their funny. If they can’t find it, you should find another doctor.
We all need to work together to break each other up. Laughter can comfort, can calm, it can even heal.
That’s real disruptive health care, no prescription required.
Casey Quinlan covered her share of medical stories as a TV news field producer, and used healthcare as part of her observational comedy set as a standup comic. So when she got a breast cancer diagnosis five days before Christmas in 2007, she used her research, communication, and comedy skills to navigate treatment, and wrote “Cancer for Christmas: Making the Most of a Daunting Gift” about managing medical care, and the importance of health literate self-advocacy. In addition to her ongoing work as a journalist, she’s a popular speaker and thought leader on healthcare system transformation from the ground up.
https://powerfulpatients.org/pen/wp-content/uploads/Casey-Quinlan-2.png600600Casey Quinlanhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngCasey Quinlan2019-01-14 17:19:482019-09-02 12:28:42Finding the Funny When the Diagnosis Isn’t
MPN specialist Dr. Joseph Scandura from Weill Cornell Medicine answers patients’ burning questions.
Greetings from southern California. I’m Andrew Schorr from Patient Power. Welcome to this Patient Empowerment Network program where you can ask an MPN expert your question. I’ve been living with an MPN, a myeloproliferative neoplasm myelofibrosis, since 2011. So, believe me, I have questions and I want answers just like you. I want to thank the Incyte Corporation for its financial support, but tell you, of course, that all the editorial control is our expert and our producers and me. Nobody tells us what to ask or what to say.
Okay, let’s meet today’s MPN expert. Joining us from New York City is Dr. Joseph Scandura. He is with Weill Cornell Medicine in New York City and he is also the scientific director of the Richard T. Silver Myeloproliferative Neoplasm Center at Weill Cornell Medicine. Dr. Scandura, welcome and welcome back to Patient Power. We’ve had you before. Thanks for being with us.
Thanks for having me, Andrew.
Okay, and I should mention that Dr. Scandura is a physician-scientist, so you can see that whiteboard behind him. He spends time in the lab, as well as seeing patients, in-patients, and in clinic. So, he is meeting us, but also working on a cure and we’re gonna talk more about that and hopefully, we can get there. Okay, are you ready for our first question Dr. Scandura?
Okay. So, this one comes from Philip who writes and he says, “I’m a 63-year-old male with PV, polycythemia vera. What does it mean that my blood is too thick?”
What it’s probably referring to, the term too thick is a little bit – can be generalized in a lot of different directions. It’s a colloquial term, not really a medical term, but what people often are referring to there in the context of polycythemia vera is too many red blood cells. If you think of the blood vessels in your body as being highways, they can only accommodate a certain amount of traffic. And you being in southern California are probably aware of this, that sometimes there’s too many people trying to get on the highway at the same time and that slows everything down. You could consider the highways too thick in that situation and that’s what’s really happening in polycythemia vera.
There’s too many red blood cells. There’s about 1,000 red blood cells for every of the white blood cells there, so the most common blood cell type and they occupy about half of the whole blood volume. And when you have too many being produced, they end up causing traffic jams in the blood vessels and that is what people are trying to describe when they’re saying the blood is too thick.
And you’re at risk for stroke and blood clots?
Yeah. So, it has a lot of both short-term and long-term consequences. Short-term certainly it provides a risk of having abnormal blood clots. That can be in an artery, so that could be a stroke, an artery in your brain, or an artery in your heart, a myocardial infarction or heart attack. It can also be a clot in a vein and so these, I’m sure you’ve seen them on TV, the advertisements for DVT or deep venous thrombosis or pulmonary embolism which is usually a clot in a vein that then has broken off and traveled through the circulation and landed in the lung where it can cause symptoms there. And so, the short-term risks of a clot are certainly elevated in people with polycythemia vera when the blood counts aren’t controlled.
Okay. Just one follow up question. Philip was wondering about this too. So, we see ads on TV whether it’s the DVT medicine ads or the blood thinner ads. Does that apply to people with PV?
It can. We treat people with PV to reduce the risk of a clot, but some people are diagnosed with a clot at the same time they’re diagnosed with PV and some people, even with the best of treatment, end up developing a clot. If it’s a clot in the vein, then one of the things that is a standard of care is to administer drugs that colloquially again are referred to as blood thinners. In this context, it has a different meaning and this is a group of drugs that interfere with the blood clotting system. So, these are proteins, not cells, and it’s what – if you ever have cut yourself and you feel just with your fingers, it gets a little sticky between the fingers. That’s actually clotting.
It’s a little bit like Jell-O. It starts out liquid and then it solidifies and that’s what your body does to help prevent bleeding. It forms this sort of polymer fiber that ends up being part of the plug. And what the blood thinning medications, the so-called blood thinning medications, do is they interfere with that process. Either given by injection or given by pill, the ultimate goal is to reduce the formation of that sort of sticky acellular clot. And that’s more of a treatment and can be a preventative for future clots as well, but it’s a little different than what we were talking about before in terms of too thick blood from too many red blood cells.
Too many cells versus the quality of the cells.
Yeah, but not even the cells. A lot of the blood clotting factors are produced by your liver. They’re not from the cells themselves that are floating around in the blood.
Andrew: I’ve never understood that before. So, thanks for explaining. I should also just say one thing about Philip. He shared with us that he has AFib. So, when somebody, and that’s not uncommon atrial fibrillation, does that complicate all the treatment for somebody with PV?
Well, one of the risks with AFib, some of them can be just related to the heart, it can disturb a little bit in how the heart functions and if people have some mild symptoms, AFib can make symptoms worse just from a heart function standpoint. But one of the things that’s related to, again some of the commercials you see on TV and the rationale for blood thinners, is the heart – the atrium, the left atrium which is really what fibrillates, which is just – normally the heart is pumping like this, all together coordinated. And what fibrillation means is it’s sort of not doing that. It’s going like this and what happens is the blood and the surface of the heart ends up not being pushed out normally.
And sometimes actually clots can form on the surface of that fibrillating heart and then when they get pushed out, they can travel. And because it’s usually the left atrium where this happens, when they travel they go into the arteries and then they can form clots and that can be stroke is the big thing people worry about. So, you can have atrial fibrillation that puts you at risk for stroke and that’s why people think about anti-coagulation medications to prevent that risk. And so, again, that’s another rationale for blood thinner, although it has nothing to do with the blood being too thick. It has to do with atrial fibrillation itself.
Okay. So, two things going on. Here’s a question we got in from Julie. Julie says, “What is the significance of a very low allele burden in a JAK2 positive patient?” And may you could define allele for us too.
Sure. So, as you know, we have some of our genes from mom and some of our genes from dad and the genes that we get are always in these two copies. And so, one copy from mom, one copy from dad, and they’re mixed and matched while we’re being sort of grown up from the embryo. But what happens in MPN is sometimes one of those copies, always starts with one of them, becomes mutated and that can be for instance, in the most common mutation, in the JAK2 gene, JAK2 V617F, a particular mutation that’s associated with abnormal function of the JAK2 gene product. And so, if we have just one copy in a cell, then one copy’s normal and one copy is mutant.
So, if we are talking about that one cell, that variant allele frequency, so that’s the abnormal gene. The proportion of all the genes that are abnormal would be 50%. Right? One abnormal, one normal. But now we think about all of the blood cells, trillions upon trillions of blood cells and then we have to take sort of an average of all of those cells. Some of them will be normal, some of them will be MPN cells, some of them will have one copy normal, one abnormal, some two abnormal, and some both normal. And so, when we look in a composite from a blood draw which is generally what people are sending, it’s a representation of how many abnormal alleles are present among all of the alleles of all of the DNA from the blood cells that’s been selected.
So, what a low variant allele frequency means that the proportion of mutant alleles in that sample of your blood is low. So, low would be maybe 10% or 5% or something like that and what is the significance of that? It’s an area a little bit of some debate, but there’s certainly a number of studies that have shown a correlation between the variant allele frequency in blood and the disease type itself. So, for instance, essential thrombocythemia, or ET, generally has a lower bearing allele frequency than myelofibrosis for the same mutation. And polycythemia vera is often in between.
While we’re talking about genes, I just wanted to bring in this question from Jocelyn because we’ve been learning are we JAK2 positive, are we CALR positive, these others that you’ve been discovering. So, Jocelyn said, “In 2006 I tested positive for JAK2 V617F. In 2018 I was told that I’m not JAK2V617F positive, but that I’m CALR positive. So, is it common for mutations to change and what does it mean?”
So, it’s not common for the mutations to change in terms of going away if they’re present, although there are certainly examples of this happening. It’s not common. What is probably a little bit more common is sometimes people have one mutation or a couple mutations and then sometimes more mutations are found later. And that often, not always, is linked to the disease changing its character itself. So, somebody with polycythemia vera having more of a fibrotic phase of the disease. In this situation, it’s a little hard to know exactly what happened, but there is a fair amount of variability from one laboratory or one test type to another in terms of sensitivity and the specificity of what is being detected.
So, JAK2 may have been at a very, very low level, could have been an erroneous measure, or it could have been at a relatively low level and the calreticulin mutation wasn’t tested for. And then later somebody retested with a different test that wasn’t sensitive enough to pick up the JAK2 mutation and they looked for a CALR and now that’s coming up positive.
So, the testing modality, the type of test that’s being done, and its individual sensitivity is an important part of this story and it’s a little hard, I think even for many physicians, to sort of get their heads around because it’s not like a blood count where you have international standards and basically a half-dozen equipment makers everybody uses across the world. There’s a lot of different technologies, each of which have little wrinkles to them that can limit somewhat exactly what’s being reported.
Okay. Here’s another one we got. This was actually asked by several people. Nick, Maggie, and Philip all want to know related to phlebotomy. What are the goals of phlebotomy as a treatment and how does it work and when do you know when it’s time to switch from phlebotomy to medication?
Right. So, I just came from a conference the end of the week and this is a topic of debate among physicians. When, whether to do phlebotomy? Whether phlebotomy therapy by itself is sufficient? What are the alternatives and when to make those decisions? I would say, I can tell you what my own feeling is. I feel that there is good support to justify that, but to be totally honest, there are physicians who feel differently than I do and I don’t know if any of us can claim to be absolutely correct. But I think we can all agree that the goal of phlebotomy in the short term is basically to take cars off the highway.
If you go back to the analogy of having too many cars on the highway causing thickened blood or this sludging from the red blood cells, this is a therapy specific to polycythemia vera, is that phlebotomy is just a very simple way of taking blood out of the system, taking cars off the highway. So, if you were to imagine and I frequently imagine this in New York City, is all of the sudden a third of the cars disappeared, it’d be a lot easier to get around. And so, that’s really what the goal of phlebotomy is, is to make it a little easier on your body to pump the blood around because there’s less resistance to having all that traffic in the vessels. How much? Go ahead, you had a question.
I was just gonna say, but debate about when to leave phlebotomy behind and have medication try to do the job when you prove one or others that may be coming.
So, I think the first goal is to get people under what would be considered control. So, an adequate level of traffic. And the numbers that are generally accepted by people in the field is having a hematocrit, that’s the portion of blood occupied by red blood cells, in males it’s below 45% and in females below 42%. Although we can all argue about that a little bit. I think people settle down around those numbers.
When is too much? My personal feeling and this is where there isn’t great data, so you’re left with opinion, but my personal feeling is it depends a little bit on the patient, the convenience, and I find that people who are getting phlebotomy more than four or five times a year, it ends up being a real burden on them in terms of the amount of time that they’re having, poor control of their polycythemia vera, and the amount of time required for phlebotomy, and the amount of risk of things like iron deficiency which can cause symptoms.
And then there’s some suggestion, I wouldn’t say great data, that maybe iron deficiency or repeated phlebotomy may be a risk in the long term, although I think that data is not very clear. My biggest determinant is patients, in my experience, just get a little fed up with getting phlebotomy when it gets above four, five, six times a year.
Okay. Thank you for that. I should mention to our audience again if you want to send in a question, whether we can use it on this program or a whole bunch we’ll be doing coming up, send it to email@example.com. Okay, so here’s a question we got from Nick and all of us wonder about it. How often or do we need bone marrow biopsies so that you, as our doctor, and we are well informed about what’s going on?
So, another area where there isn’t – you know, in medicine we look for the perfect data. We’ve controlled – we treated one group of very similar patients one way, we’ve treated another group of people another way, and we compare and see who does better. What’s the better approach? This hasn’t been done for how often to check bone marrow. I think bone marrow evaluation is very important. Personally, I generally follow how the patient is doing as the primary determinant and if there are any signs that something is changing. And those signs can be how the patient is feeling, new symptoms that are arising, but oftentimes it can be just in how the blood counts are responding.
You’re on a stable dose of a medication for several years and all of a sudden it stops working or all of sudden it starts working too well. You have very low blood counts whereas before you were okay. That suggests to me something’s changing. The bone marrow is the factory for all the blood cells. So, if you wanna know what’s happening with the production in the factory you really have to look into the factory and see what’s going on. And so, that’s my personal threshold for doing a bone marrow, when I’m seeing something that’s suggesting that the factory is not functioning the way it was the last time I looked.
Okay. And for those of us who’ve had many bone marrow biopsies, and I have, hopefully where it’s done is someone who does it frequently. Usually, the anxiety we have is worse than the exam itself. It takes 15, 20 minutes, whatever and someday I’ll tell you the story of the lady down at MD Anderson who believed in voodoo and talked to the bone marrow as she was pulling it out. And it was so weird, that I was so distracted, I didn’t feel a thing, but anyway I understand it’s important.
Here’s a question that will help our friends with ET. This is from Michelle. She says – well actually now she has post-ET myelofibrosis. She says she has ASXL1 and TP53 gene mutations. Does the mere existence of these predict aggression and poor outcome? That’s what she worries about that those have been found.
Well, obviously every individual has their own history that they’re developing and so exactly what this means for you, for an individual, is different than what it would mean for a population of people with similar mutations. That’s really what we know in medicine. We look at people in a cross section and we say people who we can put into this bin tend to behave in that way, but within that bin, there are individuals who don’t act that way, the way that the others do. So, I would in myelofibrosis, in MDS, in polycythemia vera, P53 mutations are an area of some concern, as is ASXL1 mutations are also an area of some concern.
In ET it’s less well established and so I think because, if this was just ET and you had those mutations, I think many people, myself included, would say well, maybe we don’t know perfectly, but it is an area of some concern. I’m gonna keep a closer eye on you. Now that it has already evolved into myelofibrosis, I would say this is probably more like myelofibrosis where we know that P53 mutations, TP53 mutations, and ASXL1 mutations, can sometimes be some of the harder ones for us to treat. It’s something that, if an allogenic transplant is something that is possible, should at least be considered and discussed.
It doesn’t – speaking with a transplanter, getting typed doesn’t mean you have to get a transplant, but it gives you information and so I think that that would be a reasonable thing to do. Again, the decision at the end, it may not be the right decision for you, but it is something that is information for you to use in making informed decisions.
Right. I did have a consultation with Dr. Castro, who was at the time here in San Diego, exactly about that. Not to take action, but just to have the relationship and be typed, et cetera. Here’s a question we got from Paul. He says, “I was diagnosed in 2009. I take a weekly dose of 90 mg of interferon. How long can a patient continue to take interferon and what indicates a move to change treatment?”
So, we have people who have been treated for 20 plus years with interferon. So, I don’t know if there is a known duration which is too much. For many patients it’s a very well tolerated therapy, can be quite effective, and I think that it is one of the few medications that seems to have some disease-modifying activity. However, when to change? If it looks like it’s not working, it’s time to think about changing and that can be adjusting the dose, but I think if somebody has been on it for a long while, that’s when I think thinking about additional therapy, either adding another medication to the interferon or changing completely to a different medication.
Clinical trials, there’s a lot of activity in MPNs in clinical trials. Thankfully, over the past five years or so, it’s really been increasing. There’s a lot of options. There’s some drugs that we’re really pretty excited about right now in terms of thinking they might have some nice activity and talking to somebody about what might be a suitable treatment for you if the interferon was not working anymore.
Okay. Here’s a – again we’re getting similar questions from a number of people. So, Ragita, Nankin, Raven if I’m saying the name right, and Jacquelin sent in basically this question. How common is it in patients with MPNs to have bone pain? What causes it? Is there anything that can help with the pain?
So, bone pain is always on the list of symptoms reported by patients with myeloproliferative neoplasms. I wouldn’t say, in my experience, it’s one of the more common ones. It might be a little bit more common early in disease. Sometimes things like phlebotomy that you can actually have a rebound where the bone marrow is a little bit revved up to try to replace all those cells that were taken out, that can cause some bone pain. It can be seen in myelofibrosis occasionally and sometimes when the disease is becoming more aggressive or is having a – changing its pace. But the cause of bone pain, we think of as being related to sort of expansile pain.
So, the bone marrow, the factory for all the blood cells, sometimes is just working so hard that it causes, it irritates the bone fibers that are around the surface of the bone. There’s very little in the way of pain fibers inside the bone, but on the surface of the bone you have a lot and that expansile pain, that gives that sort of vague, achiness people often describe as bone pain. The treatment for bone pain in some ways is determined by what the cause is. If it’s just, for instance, a rebound after phlebotomy, it can last a day or two and then go away. And so, short-term symptomatic treatment with non-steroidal anti-inflammatories, NSAIDs like Motrin, can be helpful or Tylenol even.
But occasionally patients report a real benefit from things like histamine blockers which the mechanism for that is entirely unknown, but there’s certainly a population of patients who feel like the bone pain has gone away with medications like Claritin you can get over the counter. It’s worth a try. They are very well tolerated medications and not all patients have any symptomatic benefit, but a subset of people do. If the bone pain is related to the cells being too active, a very proliferative feature of the disease, sometimes it dictates treatment.
So, if you were on phlebotomy alone, well maybe it’s time to change to a more cytoreductive therapy and see if that can help with the pain. Sometimes it prompts additional evaluation. If you’ve never had bone pain, all of a sudden the blood counts are a little different, you have bone pain, it might be something somebody would think about doing a bone marrow evaluation for. Again, looking in the factory which is probably where the cause is coming from.
I have a couple more topics I want to cover just before we close. We’ll go just a little bit longer if that’s okay. So, Robert wrote in and said, “How does a stem cell transplant cure myelofibrosis?”
So, I’ll go back to that factory analogy. If you think of the bone marrow as being sort of corrupted by these MPN cells. You have, normally this is a very orderly factory. It’s producing a number of different lines if you think of it as a car factory. You can be producing red blood cells maybe your sports cars, and your white blood cells, your infection-fighting cells, as sedans, and platelets as SUVs, but it’s all very orderly and it should be proceeding in a regular way. And you get MPNs and somebody has just turned up the volume and are just cranking out a lot of cells. And sometimes that production starts becoming abnormal too and that’s more like in a myelofibrotic setting.
And so, what is the point of a stem cell transplant is really to clear out that factory, get rid of all the workers in there, and replace them with completely different workers to come in, set up shop, clean up the factory, and start normal blood cell production. There’s another part of it is, it’s not just the blood cells, it’s actually the immune system. And so, you’re giving the recipient an entirely new immune system. You have to wipe out the old immune system to allow the new donor cells to get a hold in the bone marrow and then they have to be educated to sort of relearn how to fight off infections and to figure out who is who.
So, graft versus host is one of the complications where those cells from another person come into the recipient and say, “Ah, I don’t know you. I’m going to attack.” And so, that can be a problem. It can be a short-term problem. It can be a long-term problem. It can be mild and it can be severe, but there’s another edge of that sword which is what we think of as graft versus leukemia effect, or in this case it would be graft versus MPN effect where some of those donor cells recognize the little differences between them and the MPN cells and wipe them out. And so, that’s really what you’re trying to do is allow that new immune system to find the bad actors and wipe them out.
Okay. You touched on something I think we’ve got to ask about and that is people are hearing in the blood cancers now the experimental and in some cases an approved approach called CAR-T, chimeric antigen receptor T-cell therapy, but again immunotherapy to train the T-cells to fight your ailment. What do you think about that in MPNs? Does it have promise?
I mean, it definitely has promise. It’s been a challenge in myeloid disease as a whole, so AML, MDS, MPNs have not been the first diseases where this has been shown to be successful, more lymphomas where it has had a lot of traction and some nice responses. What it really is it’s a living drug and this can be done in a couple different ways. They can be cells from yourself that then are treated in the laboratory so that they start recognizing these immune cells. You start tricking them into saying, “I’m going to attack this particular thing.” Even though they weren’t really trained to do that, they are now being tricked into doing that.
And so, in a disease like a B-cell lymphoma, most of them express a particular protein that’s on B-cells, CD19. So, if you take these CAR-T cells and you say, “Well, go out and kill everything you see that has CD19 on it”, it will wipe out a lot of those lymphoma cells. In myeloid diseases like MPNs, it’s a little harder. The targets are not so clear-cut and they’re shared with normal cells. There’s one area where I think it has the most promise is calreticulin because the mutation in calreticulin isn’t a tiny little mutation. It’s a mutation that causes a whole new end of the protein that doesn’t exist in the body otherwise.
And some of the calreticulin actually gets onto the surface of the cells so it’s displayed to the immune system, and so this is an area where I think there’s some promise for CAR-T cells to target those calreticulin mutant cells. There may be other targets as well and I think we’ll learn as time goes along. People are trying to target molecule CD123 which is expressed on certain abnormal stem cells. The problem is it’s expressed at relatively low levels on those cells. It’s also expressed on normal cells and it’s expressed at higher levels on much more common cells. So, it makes it a somewhat imperfect target, and also difficult from a drug standpoint because there’s a lot of people wearing the same mask, only some of them you want to kill. So, it can be a problem.
Okay. You have quite the analogies. But, I’m just gonna ask you about two more questions and then we’re gonna have to go. This came in from Linda who says, “I am CALR positive and I have many symptoms. What causes vision symptoms for me and migraines? Can that be tracked to the CALR somehow?”
It’s common in a subset of people with MPNs. Sometimes it’s linked to the platelets themselves, to the white blood cell count, so I would certainly unless there’s a reason not to try aspirin, that’s something that can help with patients. It may also be an indication for cytoreductive therapy, so actually trying to lower the blood counts. I don’t know exactly what disease that Linda has, but it’s one that I would think is a symptom that would warrant therapy because it can be quite bothersome.
The vision changes is something that may be related to the migraines, but it’s also something that might prompt a visit to an ophthalmologist so they can actually look at the blood vessels in the back of the eye and sometimes what happens is you can have a little irritation of the blood vessels or even clots in those blood vessels and that’s something that would definitely trigger a change or new therapy.
Dr. Scandura, our audience is saying, “Please, one more question, one more question.” So, if I can a couple more. Philip said, “Is iron deficiency a new normal if you have PV and you’ll, therefore, have weakness, fatigue, maybe even some cognitive issues because of anemia as well?”
Yeah, so I sort of fall in the camp, as I mentioned before, there’s some debate in the field and I sort of fall in the camp that if you’re getting symptoms from iron deficiency, it might suggest that something other that phlebotomy could be beneficial or could relieve that symptom. Everybody, if you take enough blood out of them, is going to become iron deficient and, in fact, most people diagnosed with polycythemia vera, if tested, actually meet the criteria for iron deficiency, not because they actually don’t have enough iron in their body, but because all of the available iron is soaked up in making red blood cells. Red blood cells are red because of iron.
So, if you think about all of the iron in your body and all of the places it’s used for metabolism and everything else, there’s a lot of enzymes that actually use iron as part of their catalytic site. A large proportion of all of the iron in our body goes to making red blood cells. In polycythemia vera, that regulation is completely abnormal and you end up just making a lot of red blood cells that aren’t needed and it soaks up all the iron. Then when you start doing phlebotomy, you’re taking all of that extra iron and you’re taking it out, but the bone marrow still wants to try to make red blood cells. So, it continues to scavenge as much of the iron as it can.
So, iron deficiency is pretty common and if you need a lot of phlebotomies it’s universal. Some patients, in my experience, meet all the criteria for severe iron deficiency have very little in the way of symptoms. Others meet criteria for mild iron deficiency, but they’re quite symptomatic. And so, in those instances, you need to individualize a little bit. At least give a try to a different therapy and allow the iron stores to normalize and see if that improves the symptoms.
Okay. You used the word individualize and that’s where I wanted to wrap up. So, you alluded to earlier, that you were encouraged by new medicines coming for MPNs and you have your whiteboard behind you where you’re charting things and I hope, Joe, coming up with a cure of tomorrow for all of us. How encouraged are you in the near term and the longer term for beating back or even curing these diseases?
I think we’re gonna cure these diseases, I do. I don’t know if it’s gonna be this year, but I think that the number of tools we have to understand how these diseases work and the number of new drugs that are being developed that have real promise, like real mechanistic reasons why they should work, I think is going to yield, reap rewards over time. People have heard this for a long time. The war on cancer has been going on for a long time, but I think we didn’t have the tools that we have now for that entire duration. Right now, we can sequence a genome in a week of a person. Now, do you need to do that? No, but it allows you to get a level of information that was in the past, really just fantasy world, science fiction, and now it can be done on a routine basis.
There are, virtually all of our patients, have sequencing for 40 plus genes. It allows us to know a little bit more about what their risks are, and also gives us a spectrum of targets to start hitting. There’s models that are better than what we’ve had in the past for many of the cancers that have been targeted. Breast cancer models, you know, there’s some decent breast cancer models, but they’re very complex tumors. MPNs, for better or for worse, if you look at the spectrum of genetic complexity, they’re really pretty simple meaning that they have one to half a dozen mutations.
Now mutations aren’t the whole story, but it’s a good starting point and if you only have maybe 10, 15 genes that are currently mutated in a disease, it’s trackable. You can figure this out. You can figure out what they’re doing to allow them to win and once you know that, you start figuring out how to beat them back. And so, I think that their time is gonna come. I don’t know if it’s this year as I said, but I think it’s definitely doable.
You know, CML, when I was a kid, when I was in medical school my parents had a good friend with CML who died with CML. Now, it just wouldn’t have happened. He would have been fine, but he was on, for a long time, ineffective therapy, transformed to an acute leukemia as they all did, and then it becomes really untreatable. And now we have these magical drugs, semi-magical drugs, that for the vast majority of people just – it’s a pill a day. It’s amazing.
Well, you’ve got that work on your whiteboard and in the lab and your colleagues around the world and you had told me before the program started that you all are collaborating better now than ever before. So, Dr. Joseph Scandura from Weill Cornell in New York City, thanks for what you do as a physician-scientist and thanks for spending time with us today.
It was my pleasure and thanks for helping patients through what is a difficult ordeal I think in terms of adjusting to a diagnosis and getting information.
Well, thank you for joining us and Weill Cornell folks have been great and send our best to Dr. Silver too. He’s in his 90s and still going strong.
Yeah, he’s traveling today.
Thank you so much for being with us for this Patient Empower Network program. Thanks to Incyte for helping fund our series. We appreciate their commitment to the MPN community and as always, I just sign off by saying I’m Andrew Schorr and remember, knowledge can be the best medicine of all.
https://powerfulpatients.org/pen/wp-content/uploads/scandura-1.png600600PEN Editorial Staffhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngPEN Editorial Staff2018-11-16 19:27:082019-09-02 12:28:34Ask the MPN Expert - Dr. Joseph Scandura
“Ask the Expert” session with MPN specialist Dr. Naveen Pemmaraju from The University of Texas MD Anderson Cancer Center.
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.
https://powerfulpatients.org/pen/wp-content/uploads/Ask-the-MPN-Expert.png600600Kara Rayburnhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngKara Rayburn2018-09-12 17:18:142019-09-02 12:27:34Ask the MPN Expert - Dr. Naveen Pemmaraju
The term “patient empowerment” is among the top buzzwords in health care circles, but as with many buzzwords, they can mean different things to different people. The term is most often used to emphasize the value of having patients assert greater control over their health and health care. WHO defines empowerment as “a process through which people gain greater control over decisions and actions affecting their health” (WHO 1998). This shift is due in large part to the use of technology that facilitates increased patient access to information via the Internet, peer-to-peer sharing, consumer health devices, and mobile apps.
In a recent Twitter chat, I set out to explore what it means to be an empowered patient today. The global participation of those who shared their views on the topic shows that patient empowerment is something of universal interest.
Seven Essential Components of Patient Empowerment
Information is fundamental to the process of patient empowerment. Rare disease advocate and parent, Anne Lawlor (@22Q11_Ireland) believes that “an informed educated parent is an empowered one.” Patients make the best decisions when armed with the right information. To make genuinely informed decisions about our treatment we must have access to the relevant information needed to make those decisions. “Being informed is key to empowerment for me,” says specialist palliative care social worker, Deirdre McKenna (@KennaDeirdre). “Accurate information, clearly communicated and an available space to discuss and explore options and choices.”
Research shows that access to the right information, at the right time, delivered in the right way, leads to an increase in a patient’s desire and ability to take a more active role in decision-making. Open and transparent communication and access to a patient’s own medical records is a key driver of patient empowerment. Medical Director and Consultant Surgeon, Dermot O’Riordan (@dermotor) believes to truly empower patients “we should be aiming for the “Open Notes” principles of default sharing of all documents.” As patient advocate and CEO of Medistori Personal Health Record, Olive O’Connor (@MediStori) points out, “the patient is at the very core of every single service they use – they know everything there is to know about themselves, in the home and outside of it. Yet patient records are not kept with them!”
The OpenNotes initiative began in 2010 as a year-long demonstration project, with 105 primary care physicians at three diverse U.S. health care centers inviting 20,000 patients to read visit notes online through patient portals. Findings from the study suggest that shared notes may improve communication, safety, and patient-doctor relationships, and may help patients become more actively involved with their health and health care. Evidence also shows a sixty percent improvement in the patient’s ability to adhere to medications, a major problem with managing chronic pain conditions. What is key to the discussion on patient empowerment is that this initiative “demonstrates how a simple intervention can have an enormous impact, even absent advanced technology” (my emphasis).
2. Health Literacy
While access to information is a key driver of patient information, health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” (National Library of Medicine). Health literacy should come before digital literacy. “Health literacy is crucial,” says healthcare analyst, Matthew Loxton (@mloxton), “and you cannot get empowerment without health literacy.” Soo Hun (@soo_cchsc), Programme Manager at the Centre for Connected Health and Social Care, believes “digital is a key aspect but health literacy, even basic literacy is a must. Not all things digital requires tech know-how but all health information requires basic literacy. An app for meds reminder is no use if a patient lacks understanding of why medication is needed in the first place or why they need to be taken promptly. We spend too little time transferring knowledge to patients.”
This transfer of knowledge is crucial to the empowerment process, according to Olive O’Connor. “At the first point of contact with the patient,” she says, “education on how, what, why, where and when in relation to a condition or medication should be talked through fully. All other tools (digital, leaflets etc.) should come after the conversation which is key to empowerment.”
3. Digital Literacy
Cornell University defines digital literacy as “the ability to find, evaluate, utilize, share, and create content using information technologies and the Internet.” It’s interesting to note that opinions vary on whether digital literacy is essential to patient empowerment. RN turned patient advocate and health activist, Kayoko Ky Corbet (@kkcorbet) doesn’t believe that “digital literacy is an absolute requirement, but the ability to find accurate relevant information, and understand the information is.” Breast cancer advocate, Jennifer (@vitalfrequencis) agrees that “digital literacy is not fundamental and should not be part of the equation. Empowerment needs to be across all socioeconomic groups. Otherwise…a whole bunch of patients may never be empowered.”
Dermot O’Riordan is convinced that “whilst it sounds nice to say that digital is not ‘necessary’ for patient empowerment, in practice it is going to be pretty tough to do it properly/completely without digital.” Transplant recipient and rare disease patient, Carol McCullough (@Imonlyslightly ) also believes “digital literacy strengthens the empowerment process.” She too points to “access to your medical information online” as a key component of the empowerment process. “Knowing your personal medical data is strength, as is education about your illness,” she says.
Maternity campaigner, SeánaTalbot (@SeanaTalbot) believes that “those with long-term conditions and access to technology have a better chance of accessing information and support.” Indeed many patients have found in the online world of peer-to-peer healthcare an environment in which they are supported to become a more empowered participant in their healthcare. As I look back on my own empowerment journey, my progress was advanced step-by-step by learning more about my disease initially from doctors, then through Internet searches, and most helpful of all through patient peers online. Finding and being part of a patient community can be an important step on the path to empowerment.
Self-efficacy, as it relates to healthcare, is belief in your ability to effect change in outcomes so that you can achieve your personal health goals. The patient empowerment definition which comes to us from the European Patient Forum describes empowerment as a process that “helps people gain control over their own lives and increases their capacity to act on issues that they themselves define as important.”
Developing a sense of personal control over your health is in itself empowering. The empowered patient is confident in their ability to manage their condition. When unsure about where to go or what to do next they will feel confident to ask questions of the healthcare professionals providing their care. This confidence comes easier to some than others, and even the most confident may need guidance from their doctors in managing their disease. Endocrinologist, Iris Thiele Isip Tan, MD (@endocrine_witch) points out that “some of my patients are surprised when I teach them how to adjust/titrate insulin doses. Apparently not all MDs ‘allow’ this. Some need handholding because they get anxious about the responsibility.”
Digital leader and physiotherapist, Linda Vernon (@VernonLinda), believes “for authentic patient engagement to occur, we need to establish what the patient brings to the table, something akin to an individual, personal take on Asset-Based Community Development – perhaps we could think of it as Asset-Based Personal Development, supporting the patient to tap into their own internal, community or environmental resources to improve their health and wellbeing. Engaging patients should be as much about exploring what they can do for themselves and to help the health and care system, as what we professionals can offer to the patient.”
5. Mutual Respect
The healthcare professional is the most important contact point for the patient and the system and (dis)empowerment often manifests in the patient/professional relationship. At the heart of the empowerment approach is seeing the patient-professional relationship as a partnership of equals. Carol McCullough describes it as a reciprocal process of “mutual respect for what each person knows and being allowed to make informed choices. It is not about command and control.”
This is a partnership approach that seeks to balance clinician expertise with patient preference. It recognizes that while healthcare professionals are the experts in their knowledge of a disease, patients are the experts by experience. The empowerment process is about sharing both knowledge and experience to set new goals and learn with and from each other. Dr Kit Byatt (@Laconic_doc) agrees. “Many patients are experts”, he says, “especially rare disease patients. I’ve learned from many in my career.”
Building better relationships and seeing the patient as more than ‘just a patient’ was a recurring theme in the Twitter chat. Elena Vaughan (@StigmaStudyIE), who is researching the impact of HIV-related stigma in Ireland, believes that “an empowered patient is treated with respect, involved in shared decision-making regrading care and treatment, and is not patronised. For people with chronic conditions, effective communication, continuity of care and establishing a relationship of trust is very important.” Sometimes, as ME blogger and patient advocate, Sally Burch (@KeelaToo) points out, “not all patients are lacking confidence to speak. The problem is being heard.”
Patient and community advocate, Triona Murphy (@Murpht01) advises doctors to get to know your patients as individuals. “Know your patient!!…and their family,” she says. “No one size fits all! BUT there was/is still a culture of the ‘person’ stops at the door of the hospital and that person is now a patient.’” As antibiotic resistance campaigner, Vanessa Carter (@_FaceSA) says, “I might be a patient but I am also a creative director by profession. No one recognises me on that level. They see me as an underdog.”
6. Shared Decision Making
This partnership approach allows for Shared Decision-Making (SDM) – the conversation that happens between a patient and clinician to reach a healthcare choice together. Examples include decisions about surgery, medications, self-management, and screening and diagnostic tests. There is ample research which suggests that health outcomes are better in patients who are more involved in decisions about their treatment.
In the SDM model, the clinician provides current, evidence-based information about treatment options, describing their risks and benefits, and the patient expresses his or her preferences and values. Matthew Loxton points to how seldom we have metrics to track whether patient goals are being met. “Yet this,” he believes, “is THE most important part of quality.”
7. A Facilitating Environment
Linda Vernon defines patient engagement as “activating the person’s inner assets and supporting them to make the best use of them.” Being supported is a key component of patient empowerment. Many patients would like to take more responsibility for their own health and care, given the opportunities and support to do so. Empowerment does not happen in a vacuum: it is a two-way process. The patient needs a counterpart in the health professional who welcomes the patient’s involvement and knows how to create an enabling healthcare environment. Kayoko Ky Corbet states she became an independent patient advocate when she realized most doctors simply do not have the time (and often skills) to take this facilitating role and promote shared decision-making that patients desperately need. As Patient Critical Co-op (@PatientCritical) puts it, “if you have a patient who wants to advocate for themselves, and become informed, you also need a doctor that respects the patient’s right to share decision making.”
Is It Empowerment or Participation?
Not everyone likes to use the term “empowerment”, as it implies that it is an authority given to someone to do something. “I balk at the idea that professionals can ‘give’ (usually on their terms) power to the powerless,” says Alison Cameron (@allyc375). “We need to create conditions whereby people can “empower” themselves.” Seána Talbot agrees that patient empowerment “doesn’t mean ‘giving’ people power.’ Rather it’s about ‘enabling’ them to recognise and use their power.”
Perhaps the term ‘participation’ (which is a more active state) is preferable? This distinction is important because empowerment cannot be imposed ‘top down’ (although it can be facilitated). Sharon Thompson (@sharontwriter) believes that “patients should not be pressurised or need to be in a position of ‘power.’ It should be automatic that a patient is central and key to their care. Patients are automatically empowered when they are respected as being people who are entitled to understand and know about their care.”
Neither is patient empowerment about the patient taking full control or shifting responsibility to the patient. “If the empowerment amounts to abandonment”, says Matthew Loxton, “then the patient’s health goals are not being met. Patient empowerment should never be an excuse for abandoning or burdening the patient.”
Rather, the empowerment approach, as defined by the European Patient Foundation (EPF) “aims to realise the vision of patients as ‘co-producers’ of health and as integral actors in the health system.” Caregiver Reinhart Gauss (@ReinhartG) agrees that “patient advocates want to work with not against doctors – to share experiences and to grow in knowledge.” Vanessa Carter is clear that “we still want our doctors, but they are not there 24/7 so patients need the right tools to make self-care possible.”
Equally, it is about recognizing that there are degrees of involvement and not all patients wish to be ‘empowered.’ There is a spectrum of interest in wanting to assume an active role in care – from being passively receptive to fully engaged. It is up to the patients themselves to choose their own level of engagement. Pharmacist Chris Maguire (@chris_magz) sees this choice as the essence of empowerment. Patients “get to decide how much they want to look into things and take control. Or they want to be guided on the journey and have trust in their healthcare providers. But the key is that they decide the level of interaction and are not dictated to.” Kayoko Ky Corbet agrees that “true patient empowerment should be about helping patients get involved at their highest potential or at the level they choose.” However, she says “it’s also important to keep the option of involvement open. Ideally patients should get opportunities to change their minds to participate in decision-making later.”
Empowerment as an Ongoing Process
Empowerment is a non-binary, non-linear process. Your needs may change over time. You might feel empowered in a certain context, but disempowered in another. Healthcare communicator, Michi Endemann (@MichiEndemann) makes the distinction that “talking about empowerment as a healthy person is quite different than talking about it as a patient.” As patient advocate, Rachel Lynch (@rachelmlynch) puts it, “it can be quite tiring being empowered when all you want to be is well.” A sentiment echoed by Kathy Kastner (@KathyKastner), founder of Best Endings, who clarifies how “to me ‘empowered’ assumes I’m feeling physically and mentally up to the task of ‘being engaged’. I’ve seen powerhouses who cannot bring themselves to take responsibility for their own health.”
Mental health advocate and co-founder of #DepressionHurts, Norah (@TalentCoop) calls attention to the fragile nature of empowerment. “Even the strongest can quickly feel disempowered by a deterioration in health,” she says. “Fear disempowers. Sometimes it’s a case of ‘can’t’ not ‘won’t.’”
For those who feel ready for a greater degree of participation in their healthcare (and that of their family and loved ones), Jennifer advises that “being willing to self-advocate, along with self-confidence, communication skills, compromise, research skills, and relationship building” are some of the key traits and skills you need to become an empowered patient. Terri Coutee (@6state), patient advocate and founder of DiepCjourney Foundation, adds that “empowered patients do their research, ask questions, go to appointments organized, and take a friend to help listen.”
Barriers to Patient Empowerment and Overcoming Challenges
What are some of the current barriers to involving patients more in their care? Jennifer points to a “lack of adequate time during the doctor’s visit (on both sides), language barriers, technology barriers, generation gaps, and cultural gaps.” The solution? “All solved by building good relationships,” says Jennifer.
Norah also calls attention to the technology barriers. “For older patients simple things like communication (hearing), or uninformed changes are extremely disempowering; as is over reliance on technology for a generation who may not have ‘tech’ understanding or access.” Tim Delaney (@FrancosBruvva), Head of Pharmacy at a leading hospital in Ireland highlights the fact that “in acute hospitals we treat huge numbers of elderly people whose engagement with social media and new technology is lower. We need to design technology that meets their usability needs AND use whatever suits them best be it old tech or new.” Soo Hun agrees that “the tech savvy few have quicker and better access to health information and therefore can have choice and autonomy. To reverse that we need to make technology ubiquitous and make health information and choice easily accessible.”
Whilst Vanessa believes it should be “governmental policy to have digital resources in place, for example, disease specific websites / apps supported by health authorities,” Kayoko believes it can start with “tech-savvy advocates (like me) who could help patients learn to use simple digital tools.”
Matthew Loxton sees a core barrier to empowerment to be “the large knowledge/power gradients between patients and health care providers. Without access to their data, trustworthy sources of medical knowledge, and the power to execute their choices in achieving health goals, empowerment is an empty phrase.” Triona Murphy echoes this systemic challenge by clarifying that “the whole system needs to understand the patient’s right to be equal partners in their care. IF that is what the patient wants.”
Sometimes the fear of being labelled a difficult patient can be a barrier to empowerment. “Some patients feel uncomfortable challenging the judgement or actions of their caregivers for the fear of being labelled as ‘difficult’, of offending staff and/or because of concerns of compromising their healthcare and safety,” says Tim Delaney.
Not everyone wants to be empowered in making decisions about their care, and not every doctor wants to take the time. Some doctors use medical terminology which is incomprehensible to patients, while some patients have low health literacy skills or come from cultural backgrounds that lack a tradition of individuals making autonomous decisions. That said, Carol McCullough points out that while “not everyone may want to be empowered, for the health service to be sustainable, more people are going to have to take on more responsibility.”
Medical Doctor and Chair of Technical Advisory Board, Pavilion Health, Dr Mary Ethna Black (@DrMaryBlack) points to the inevitability of the shift towards patient empowerment. “Empowerment is an inevitable shift that is happening anyway, “she says. “We cannot turn back the tide or turn off the internet.”
Kayoko Ky Corbet agrees that we “must understand that patients making informed decisions is the ultimate way to reduce waste, pain and regrets in healthcare. It’s also morally the right thing to do!” Patient Critical Co-op also believes in the moral imperative that “empowerment essentially means a group or society recognizing your right. Patient empowerment exists as an action patients can take to improve themselves, but the key to achieving that improvement is having a group, organization, or state enshrine and recognize those rights.” In fact, the Alma Ata Declaration defined civic involvement in healthcare as both a right and a duty: “The people have the right and duty to participate individually and collectively in the planning and implementation of their healthcare.” The Declaration highlights the collective dimension of empowerment and the importance of action towards change. By working together to think internationally and act nationally we can draw on each other’s experiences so that as individuals and as a collective we can work towards better outcomes for all patients. To quote Terri Coutee, “When we gather our collective empowered voices, we feel a strong responsibility to give voice to others.”
I would like to acknowledge the assistance of Dr Liam Farrell in facilitating the Twitter discussion on which this article is based.
A Stanford Medicine X e-Patient scholar, Marie Ennis O’Connor is an internationally recognized keynote speaker, writer, and consultant on global trends in patient engagement, digital health and participatory medicine. A board member of the Patient Empowerment Foundation, a network of people, foundations, organizations and medical institutions dedicated to empowering patients worldwide, Marie’s work is informed by her passion for embedding the patient voice at the heart of healthcare values. She writes about the experience of transitioning from breast cancer patient to advocate on her award-winning blog Journeying Beyond Breast Cancer.
https://powerfulpatients.org/pen/wp-content/uploads/What-Does-It-Mean-To-Be-An-Empowered-Patient_.png600600Marie Ennis-O'Connorhttps://www.powerfulpatients.org/pen/wp-content/uploads/New-Logo-300x126.pngMarie Ennis-O'Connor2018-05-22 17:22:012019-09-02 12:34:33What Does It Mean To Be An Empowered Patient?
My journey began in 1999 when I was diagnosed with Essential Thrombocythemia (ET). All I took was a baby aspirin, even then they [platelets] soared to over 1 million.
In November 2004, I had a bad cold and had this aching on my left side. It was discovered my spleen was enlarged and I had a bone marrow biopsy. I was at that time diagnosed with Myelofibrosis (MF). I went to see Dr. Richard Silver in New York and he put me on Interferon. I saw him for 5 years and then transferred to Cleveland Clinic as my insurance company was making it harder and harder for Dr. Silver to be paid. There I was under the very capable care of Dr. Ramon Tui. It was under his care that I did a trial for Jakafi. It only helped the spleen size for a couple of months, but it has kept some of the other side effects of the disease at bay. I still take 20 mg. twice daily. Also, in 2014 I had a double mastectomy.
In the spring of 2017, I was so horribly uncomfortable because by this time I looked 9 months pregnant with my spleen. I also had swollen legs and feet. I could hardly walk. I made a decision at that time to radiate the spleen to give me some relief. I was supposed to receive 10 treatments, but was stopped at 7 because my blood counts bottomed out. Hmg 6.0, Pl 5, WBC 0.8. I started with transfusions twice weekly of one platelet and two blood. I did this for several weeks and developed a horrible headache. I stopped the transfusions and my Dr. said to go home and call Hospice. He thought I had 2 weeks to 2 months to live. I was really sick, but as my spleen began to recover, my counts went up. By the fall of 2017, I was basically back to normal with the blood counts and, of course, out of Hospice. My family think I’m a miracle. But, the spleen, by December 2017 was becoming very uncomfortable again and I started radiation again January, 2018. This time I had 4 treatments and had to stop because of my blood dropping.
It has been suggested to me by two doctors to have my spleen removed and have a bone marrow transplant. But, I have read about this procedure and I know I wouldn’t survive as I am very sensitive to most of the medications they would have to give me. My current hematologist is looking for a trial I can do, but my bone marrow is nothing but fatty tissue. I have nothing there…not even fibrosis. I keep telling them my spleen is doing it all, but they won’t believe me. With no bone marrow tissue, I can’t do a trial. So, I don’t know what they are going to do with me. Anyone else have this problem? I’d love to hear what you are doing.
I know the Lord has a good plan for me and I just have to wait and see what it is. He is the “great physician”! I’m just not real patient. I haven’t felt really well for a long time.
The Community Transportation Association estimates that approximately 3.6 million Americans miss or delay medical care because of transportation issues that cost the health care system $150 billion each year.
To help combat this issue, Uber has created a new app called Uber Health. Earlier this month Uber announced that they are working with providers to offer reliable rides for patients, care partners, and families to get to and from doctor’s appointments and the hospital.
The app will allow medical and administrative staff to either call an Uber to drive a specific patient home, or to dispatch an Uber to the patient’s house for pick up. The app also allows users to schedule the ride up to 30 days in advance, so important appointments are never missed. Planning transportation in advance enables patients to schedule rides to and from follow-up appointments even while they are still in the healthcare facility. With the ability to schedule and manage multiple rides from a single dashboard, healthcare professionals can take their level of care to the next level with Uber Health.
How It Works
Uber Health saves patients time and money, as they can focus their attention on their health instead of worrying about how they might get to their next appointment. With the help of Uber’s cost-saving methodology, patients and healthcare professionals can save money utilizing the app over hailing taxis or paying for expensive hospital parking.
Uber Health enables older patients and those with chronic pain gain independence and mobility. Because all communication with Uber Health is completed via text message, patients no longer need a smartphone and the corresponding Uber app to access Uber Health’s benefits.
The Uber Health dashboard was designed with HIPAA standards in mind, ensuring that all aspects of the service meet health care privacy and security standards.
As a part of Uber’s beta program, over 100 healthcare organizations in the U.S, including hospitals, clinics, rehab centers, senior care facilities, home care centers, and physical therapy centers are already using Uber Health.