Specialty Pharmacy and the Patient Journey with Specialty Medication
In this segment of A Conversation With, Becky Pleat the Associate Director of Medical Managed Care Oncology Specialist at Sanofi discusses specialty pharmacy and the patient journey. Becky answers the following questions:
- What is a specialty drug?
- What is a specialty pharmacy?
- Where can patients find a specialty pharmacy?
- How do patients receive a specialty medication?
- Will a specialty medication be covered by a patient’s health plan?
- What kinds of services and/or resources are offered at specialty pharmacies?
Managing medications can be difficult to do, especially if you’re a senior caregiver. Helping someone else remember to take medications on time and work to find the right balance for them can seem like a daunting task. Thankfully, we’ve got a list of tips and tricks to help make things flow more smoothly.
Make Sure Providers Are Aware Of Vitamins And Supplements
Medical providers should be aware of any vitamins and supplements a person is taking. Regardless of how natural they are, they can interfere with medications and other treatments. For example, someone on blood thinners should not be taking a supplement with vitamin K. Most blood thinners work by inhibiting the production of this vitamin in the body. Taking a vitamin K supplement can negate the work of blood thinners.
Make sure to go over medication instructions with the senior you’re caring for. If they are able to, they should know the names of each medication along with dosages and what times to take them. It doesn’t hurt to type up instructions about medications so that all information is in one place and easy to access. Consider adding in what side effects they should seek help for. That can serve as a list for caregivers and seniors to check on in case of adverse events.
Set alarms to remind seniors to take their medications. There are many options to choose from. Smartphones allow you to set up reminders with different sounds each time which can help people differentiate between medication doses and other alerts. Electronic personal assistants like Alexa or Google Home can easily be used for reminders as well. If the senior you’re caring for struggles with newer technology, consider a few alarm clocks around the home.
Keep A List
Keeping a list of medications can help seniors and caregivers alike remember what medications are due at what time. Lists that have both a visual of what the medications look like and allow people to check off a medication dose can be useful tools. If you’re going with this kind of list, make sure that you have multiple copies. Placing one next to a pill organizer and another on the fridge can help remind people to take medication before they’ve even missed a dose.
Smartphone apps can also be helpful in tracking this information.
It’s important not to just set alarms or reminders, but check in to ensure that someone has taken their medication. It can be easy to turn off an alarm and still forget to take medication as scheduled. Following up with the senior in your life can remind them that they didn’t take their most recent dose.
Store Medications Properly
Most medications do best when stored between 68 and 77 degrees Fahrenheit. Additionally, many of them need to avoid humidity, direct sunlight and more. Medications should not be stored in vehicles, on windowsills or other sunny and warm spots or even in the bathroom. Consider storing them in a cool, dry space in the kitchen or living space.
When medications aren’t stored properly, it can affect their potency and make them potentially dangerous. If you’re concerned that your senior’s medications have been affected, here’s what you need to watch out for:
- Odd smells
- Discolored pills, tablets and injections
- Cracked or crumbled pills
- Pills and tablets that are stuck together
- Creams and ointments that show separation
- Cloudy injections
If you see these signs, contact your senior’s pharmacist as soon as possible.
Sort Medications Into Pill Organizers
Set aside time each week to go through the medication your senior takes and place them into pill organizers. These can make it easier to remember to take medications as prescribed or even transport them while traveling. Some organizers can remind people to take their medications and even alert others that a dose has been missed.
Make Sure All Caregivers Know About Medications
A sure way to have seniors miss their medication doses is to have senior caregivers who aren’t on the same page. Without everyone being in the know, it becomes increasingly difficult to set reminders and follow up with seniors about medication doses.
Plan Ahead For Refill Needs
Refills may come up on days where a senior is alone. When that’s the case, they may forget or be unable to pick up their refilled medications. Refills may even be due when someone is planning to be out of town. Make sure to plan ahead adequately for refills and work with a person’s pharmacist.
Consider Compounding Medications If Needed
Compounding is a process where medication is tailored to a person’s specific needs. This can help remove any dyes a patient is allergic to or turn a pill into liquid for those who struggle with swallowing pills.
Get Tips from A Medical Provider
When methods to help your senior aren’t working as well as you had hoped, take some time to check in with their medical providers. Nurses have amassed a wealth of information on improving their patients’ quality of life. They are likely to have some ideas on how to make managing medications more effective.
Always Communicate With Family Members
Whatever steps you take to maintain a senior’s medication schedule, make sure that you’re communicating any difficulties with the senior’s loved ones. Family should also always be aware of any medication changes. When so many seniors rely on a variety of paid and family caregivers, it’s incredibly important for everyone to be in the loop on the storage, administration and organization of all medications, vitamins and supplements.
Susan Ashby joined the Superior Senior Care team in July of 2014 as Community Relations Manager. With over 27 years of experience in geriatric health, Susan brings a wealth of knowledge and insight to Superior Senior Care and plays an integral part in connecting consumers and communities with resources for independent living.
Clinical Trial Mythbusters
In this MythBusters program, Senior Vice President and Chief Medical Officer (CMO) of ASCO, Dr. Robert Schilsky, and 20+ year CML survivor, Mel Mann along with Cecelia Mann, will unpack some of the issues that have led to the lack of diversity in clinical trials and initiatives in place that are changing all of this.
And greetings from near San Diego, Carlsbad, California. I’m Andrew Schorr from Patient Power. Welcome to this Patient Empowerment Network program, the next in our series Clinical Trial Mythbusters, and this program is so important, discussing what is the value of diversity in clinical trials. And, believe me, you’ll hear it is so critical. We have to do better, and we’re going to discuss that over the next hour.
I want to thank the companies that have provided educational support through grants to the Patient Empowerment Network. They have no editorial control, but their support is welcome. And that is AbbVie Incorporated, Astellas, Celgene and Novartis. All right.
We’ve got a lot to discuss today, and we welcome your questions along the way. I want to first introduce someone who, like me, has greatly benefited from a clinical trial and believes that they are alive today because of their participation. And so joining us from Atlanta is Mel Mann along with his wife and care partner Cecelia Mann. Mel, welcome to the Patient Empowerment Network program.
Thank you very much.
And we’re going to hear more of Mel’s story in just a minute. I want to introduce a very prominent medical expert who joins us. He is the senior vice president and chief medical officer at really the largest cancer organization, the American Society of Clinical Oncology, and that is Dr. Richard Schilsky. Dr. Schilsky, welcome to our program.
Thank you, Andrew. Happy to join you.
Okay. And are you in the Washington, DC, Virginia area?
That’s where our organization is based, in Alexandria, Virginia, yes.
Thank you for being with us. I should mention that Dr. Schilsky has had a lot of experience related to trials. He was the head of hematology/oncology at the University of Chicago, which of course Chicago is a very diverse city, and the University of Chicago does a lot of research. And he also helped run a big research group that doctors from around the world are part of, and he did that for many years. So we’re going hear more from Dr. Schilsky in just a minute. But, first, Mel. So Mel, in the late ’90s you were dying, right, of chronic myeloid leukemia, correct?
Yes, I was.
Losing weight and being told that there wasn’t much to do, right?
Maybe a transplant. But you were in Atlanta and you went from doctor to doctor, but somehow you got to MD Anderson, a major research center in Houston. What did they offer you there?
When I first went out to MD Anderson they said they were going to put me on a clinical trial after clinical trial. And the first thing they did was increase my dose of interferon, and that was the medication, the standard therapy at the time, and then they tried different combinations of drugs, and eventually I started on different clinical trials.
Okay. And, Cecelia, you were there in Atlanta and he was scooting over to Houston, it’s not exactly around the corner. Why were you supportive of that?
I was supportive of that because that was the last chance that he had to a cure and for survival. So from the very beginning, whatever type of treatment he needed when he was flying around, whether he was going looking for bone marrow transplants, doing bone marrow drives, and therefore I was supportive of. We had a five‑year‑old daughter at the time, and so anything that Mel needed I was there to support him.
So, Mel, this is a happy story because here we are in 2018 as we do this program and you are with us when many people with CML at the time were not with us that long. Hopefully, a transplant could be curative, but a lot of people passed away. You were lucky enough to come back as they were rolling through different trials and there was a new one that opened up for a drug called Gleevec, a pill.
Okay. So in the summer of ’98 the Phase 1 Gleevec study opened up, and I went out to MD Anderson, and I was patient number two, and I started taking it at a low dose, and it was effective for me. And eventually they increased the dose and it started changing my leukemia around to eventually I reached what they call a major molecular response. And that was 20 years ago. This summer I went over 20 years.
Wow. Well, Dr. Schilsky, is that an example of a patient getting, if you will, tomorrow’s medicine today, what we hope for?
Absolutely. And, first of all, it’s such a wonderful story, Mel. It’s great to hear you tell it, and it’s exactly why we do research, exactly why we do clinical trials, to try to discover the new therapies that people need that will give them the kind of long‑term survival and quality of life that you’ve been experiencing. It’s just‑‑it’s wonderful.
So, Dr. Schilsky, let’s get into the problem. So, generally, there are many clinical trials that take longer than one would hope to fill, and the FDA and I know scientists have been seeing well, gee, how do we know what we’re testing applies to people maybe with different ethnic, gender backgrounds, a variety of situations, and often we can’t find people who fit those categories to be in. What is that‑‑how poorly have we been doing in the past with diversity in trials, and what does that mean for developing new medicines?
Well, we don’t do well in almost any dimension. We don’t get enough underrepresented minorities in clinical trials. We don’t get enough older people in clinical trials. You have to remember that 60 percent of cancers occur in people 65 years and older, and yet only about 10 percent of people participating in clinical trials are 65 and older. So we are having to treat the majority of older people, and I would say the majority of minority people, with data derived from participants in clinical trials who are not like them.
We need to change that for a whole host of reasons. It’s historically been very challenging, and the problems really sort of boil down into three big areas that I think we can discuss a little bit further.
First is awareness. Many people are not aware that clinical trials are even an option for them. Many people think that a clinical trial is a last resort, and I want to dispel that myth right out of the box. Clinical trials can be a very good option for patients right from the time of their cancer diagnosis even if it’s their very first treatment. So clinical trials may be a last resort, but they don’t have to be, and there are many clinical trials that are appropriate for people right following the initial diagnosis of their cancer.
So there’s the awareness issue, and sometimes, frankly, not even the doctors are aware of what clinical trial options are for their patients. And the one thing we know for sure is that the most influential person as to whether or not a patient goes into a clinical trial is their doctor. If the doctor does not recommend it, if the doctor is not aware of it, it’s not going to happen.
But then you get into the more technical issues. There are things, there are rules for clinical trials because they are research studies. They are experiments. There are very well defined rules, most of which are in place to protect the people who are participating in the study. Some of these rules are called eligibility criteria, and they specify the characteristics of people who can enroll in the study. Well, historically, they tend to be very rigid and very limiting, and you’ll often hear people talk about how the only people who can get into clinical trials are Olympic athletes. That may be the case, but it’s not Olympic athletes that we’re treating in the clinic every day, so we need to make our clinical trials more representative so that they’re more applicable to the typical person that a doctor sees in their office.
And then there are the logistical or operational issues of the clinical trial. The clinical trial can be very burdensome. Mel just described how he had to travel from his home in Atlanta to Houston to participate in a clinical trial. Not everybody can afford to do that. Not everybody can take time away from work, time away from home. And the clinical trial requires not only that you travel sometimes but that you travel on a specific schedule because of the requirements of the trial.
So all of these are issues that are‑‑can limit participation in trials, and many of them are magnified in minority populations or in populations that don’t have the economic resources to be able to meet the requirements of the trial.
Right. Let’s talk about that for a minute. So, Cecelia, you go out in the community and speak to people, and you probably meet some people who maybe are diagnosed with a blood cancer, like you’re active with the Leukemia and Lymphoma Society so you may speak to them, and they say even if you brought up about a trial, they say, hey, Cecelia, I’m working two jobs. Or my husband or spouse is working two jobs, and we’ve got two kids, three kids. How could we ever participate? We just can’t get away or we don’t have the family support or whatever. Those are real issues, right?
True. True, those are real issues, and I try to direct them towards resources that Mel and I found out about along the way. The Leukemia and Lymphoma Society, they have resources to help with travel, and American Cancer Society has resources that help with the hotel and lodging. And there are a number of other different types of funds that can be assessed to make that a possibility.
But you’re right, Andrew. I had one young lady at a health fair and a second cancer had popped up, and she was coming there to get information, and she was saying that they were saying it wasn’t too much they could do, and I brought up MD Anderson. And she immediately said, I can’t go out there, I have to go to work, and she turned around rough. And so when they listen to me then always glad to tell them about it and let them know there is an option and that clinical trials work, and I point to Mel, my husband, as a success story also.
So, Dr. Schilsky, you talked about physician awareness. It’s also about more physicians participating in trials at I think what you call the community level. So, in other words, MD Anderson and where you work, at the University of Chicago, those are big city centers and where they are in Atlanta there’s Emory and some other mainly centers, but what about out in the hinterland, if you will? Can somebody who lives there diagnosed with a cancer, how do they have access to a trial that their doctor knows about and maybe that’s more close to home, if you will?
Right. So of course we know that anybody with cancer prefers to be treated in their community, and most are. So one of the goals is to be sure that oncologists practicing in all sorts of community settings have access to clinical trials. Now, one of the ways that happens is that for more than 50 years now the National Cancer Institute has actually been operating and funding a community‑based clinical trials network. It used to be called the CCOP program. That’s an acronym that we don’t have to go into. They’ve recently changed the name. It’s now called NCORP program, but‑‑that stands for, I think, the National Community Oncology Research Program.
But the point is that the program, which is in most but not all of the states in the United States, funds community oncologists to participate in NCI‑sponsored clinical trials, and there are at least 65 or 70 such clinical facilities around the country right now. So in those medical practices patients can find those clinical trials in their communities without having to travel.
There are also other community‑based networks that are active participants in cancer clinical trials. So I think at the end of the day the critical thing for patients, and this is sometimes easily forgotten because you’re so, you know, your thinking and your time and your emotion are all taken up in dealing with the cancer diagnosis. It’s really important, though, to ask the doctor, do they have access to clinical trials. Do they have a clinical trial that might be appropriate for you? And if not you might want to consider where else you could go, hopefully still relatively nearby to get access to a clinical trial.
Mel, so for you, you went around to some doctors who were not aware of anything new to do for you, right? And that’s still true in so many areas of cancer. Now, what do you say to patients about speaking up because Dr. Schilsky just referred to it, people are terrified. They really just want the doctor to have the answer. What do you tell people so that they maybe advocate for themselves?
Okay. So if you’re looking for a clinical trial and I’m out at, like you say, a health fair, we have a‑‑the Leukemia and Lymphoma Society has something called the clinical trial support center, and they have nurses who work early in the morning till late at night. And you call them up and you tell them about your illness, and they check the availability for what clinical trials are out there, and then they narrow it down to what you actually qualify for, and then they take into consideration your finances and other issues.
And then you’re left with a number of possible clinical trials that you have, and you can take that back to the doctor and you can discuss that with him. So that’s one of the things I talk with them about.
I could mention, now this is really more broadly across cancer, too. So there are breast cancer groups, there are lung cancer groups, and I would just make a pitch to find out, is there a local chapter or national number for you, for the cancer you or a loved one been diagnosed with, and that’s the question.
Say, look, A, I don’t want to feel I’m alone, and, B, how do I get‑‑how do I get connected with what could be lifesaving or life‑extending treatments for me and that I could discuss with my doctor. And understanding‑‑and then, boy, if there are obstacles like financial issues, logistical issues, travel issue, is there support for that.
So let’s go back to the inclusion/exclusion or eligibility issue you spoke about, Dr. Schilsky, because, you know, somebody who has cancer may also have heart problems or diabetes or some other issue. Maybe they previously had another cancer, and so for the companies developing new drugs they may be happy with narrow inclusion criteria because they don’t want to have anything get in the way, some previous thing you’ve had, to affect their ability to have a new drug go on the market.
So what kind of work is going on between government and the drug manufacturers so that the criteria, not so tight, but you can still get legitimate scientific answers?
Right. So, as you alluded to, Andrew, there are good reasons that there are eligibility criteria. One of them is to protect the patients in the study from circumstances that would increase their risk of participating in the study. Another is because the companies or whoever is sponsoring the study wants to be able to isolate the specific effect of what they’re studying without having a lot of confounding factors that could muddy the water and makes it difficult to interpret the results. But that said, the bad thing about all that is that the results of the study might not be applicable to the majority of people who could benefit from the treatment because they weren’t included in the study to begin with.
So one of the things that my organizations has been working on very hard over the last couple of years now, and we’ve been doing this collaboratively with people from the Food and Drug Administration and the National Cancer Institute and a lot of clinical experts and a patient advocacy group, Friends of Cancer Research, is to try to expand or broaden or simplify some of these eligibility criteria that tend to keep people off of trials and in particular tend to keep minority populations off of clinical trials.
So, for example, it’s not unusual for someone who has a new diagnosis of cancer to have previously had some kind of cancer earlier in their lives. So we might see a patient who has lung cancer who 15 years ago had a diagnosis of prostate cancer. Well, for that lung cancer patient to go on a trial that has the typical inclusion and exclusion criteria that doesn’t allow for this previous malignancy, they would be excluded even if they had been cured of that prostate cancer 15 years ago.
We also see, and you mention what we call in the medical profession comorbidity. So if someone’s got cancer and they also have heart disease, they also have diabetes, high blood pressure, anything that affects the functioning of your normal organs, can also exclude people from participating in trials, and there are certain limits that we feel can be expanded and still allow the treatment to be given safely.
So just about a year ago now we came out with a set of recommendations for how eligibility criteria can be modified to make clinical trials more inclusive. And now just recently, I’m really pleased to say, the National Cancer Institute expanded their sort of template protocol document that many investigators follow to incorporate our recommendations, so now their standard protocol includes these broader inclusion and exclusion criteria. And the FDA now is working on what they call guidance documents to advise commercial companies that are running clinical trials to do just the same thing. So we are very optimistic now that we’ve got this ball rolling. We’re going to be removing these obstacles, and we’re going to be able to have more inclusive and diverse population of patients who participate in cancer clinical trials.
Great leadership. I hope it works great, and we’ll be happy to support you. So, Mel and Cecelia, let’s talk about the money part of it a little bit. So you were making trips to Houston, Mel, Cecelia was home with a five‑year‑old, and so admittedly there may be hardships, financial hardships, being away from family if you have to go to a trial somewhere else, checking back. What do you say to people when they say, well, I’m just going to go with the traditional stuff. It’s close to home. In other words, if there can be programs that can help them it still takes courage, if you will. So what would you say to people about investing in their life, if you will?
Well, you know what the standard, what the current treatment is and the outcome of that, so if you want to have a different outcome then you have to try something new which is probably going to be a new drug. So you have to weigh that with the cost and the travel. Some people may not have the support, the caregiver support to go a long distance, so you have to take that into consideration. As far as the Leukemia and Lymphoma Society they do have certain funds where they can help with travel pay, co‑pay, insurance premiums, that could help alleviate some of it. So there’s a lot of stuff that’s involved, and it’s an individual decision.
So we’ll just make a comment, though. So, many people have a church or synagogue, friends, neighbors even if they’re living alone, but yet people are sometimes hesitant to ask for help. And I would say speak up. People do want to help you.
Dr. Schilsky, let’s talk about another reality of trials. There’s a history certainly and some fear still in the black community of whether they were tested on, without their knowledge even, going back years and the general thought, you’ve heard it through your career, I’m sure, people say, well, I don’t want to be a guinea pig for a couple reasons. One is we don’t know if it’s going to work. And second of all if there are different arms of a trial I don’t know if I’m going‑‑I’m going to go to all this trouble and expense, I don’t know if I’m going to get the good stuff. So maybe you could speak about that a little bit. First of all, the fears of being experimented on, and then also about whether you will get what could be a breakthrough.
Yeah. Well, for sure, you know, there is this sort of sordid history of inappropriate experimentation on people, and clinical trials are a form of experimentation. They are a form of research. There’s no doubt about that. But clinical trials these days are highly regulated, overseen by independent groups that include patients and clinical experts that come together in committees called IRBs, Institutional Review Boards, and they evaluate on both the risks and the benefits to patients who participate in clinical trials.
They make sure that the trial has an appropriate consent process associated with it, that it’s explained in plain language to patients, so I think these days a lot of those concerns no longer exist. And I hope that people can get beyond the history that led to some of those concerns. The‑‑sorry, I lost a train of thought on the rest of your question.
The issue about are you going to get the good stuff.
Oh, yes. So a couple points there. One point I want to make clearly is that in most cases cancer clinical trials do not include a placebo or an inactive treatment. That’s not always the case, but it’s true most of the time. So patients are always going to get at least the standard of care treatment, and of course the standard of care is what is at that time known to be the best available treatment.
The whole point of doing the research is to determine if the new thing is better, and of course we always hope it will be. It’s not always better, but sometimes it is, as in Mel’s experience. And I think this has to be clearly laid out to patients. They have to clearly understand why the research is being done. In many trials nowadays even if the patient is assigned to get the standard of care treatment there still may be an option to get the new treatment at a later point. So if the standard of care doesn’t work many times there’s still the opportunity to get the new treatment following the standard of care treatment.
So the trial really boils down to not standard versus new but new versus standard followed by new. So eventually everybody may have a chance to get the new treatment. That’s not always the case, but I think the key‑‑my key take‑home, in a sense, is that we’re doing the research because we think and we hope the new treatment is better, but we have to do the research to prove that. And everybody in a clinical trial I think can be assured that they’re going to get, at the very least, the best available standard treatment.
Mel, when you signed the papers to be in a trial, and you probably shared them with Cecelia, especially back in the late ’90s and I participated in one trial in 2000 and another in 2011, there’s a lot of paperwork, things in bold face written by lawyers. I didn’t always understand it. What propelled you beyond that? Was it just that, oh, my god, if I don’t get something I’m going to die? Or how did you two deal with the paperwork and feel comfortable signing on the dotted line?
Well, I saw a lot of hope in the paperwork. For example, one trial I was on was peginterferon, and I had been taking interferon every day, injecting myself, and I had to keep it refrigerated and when I travelled it made it difficult. So with peg I can take one shot a week, so that would make the cancer journey easier. It may not make me live longer, but it will improve my quality of life, so I saw my quality of life improving with that clinical trial. And I looked at the paperwork, and I went through it, and I felt comfortable with it.
And how about you, Cecelia? I mean, your husband says, well, I’m going to be in a trial and I’ve got to sign all these papers. Did you say at any point, wait a minute, that’s scary?
Well, no, I didn’t. I didn’t because with Mel, he had three years to find a marrow match, and he was at the end of year two and no match in sight. And so when he had the opportunity to go out to MD Anderson and be on a clinical trial or several, I was okay with that. I was okay with that. And I looked at it as actually being a blessing. And it turned out to be, and we’re grateful.
But I would say to anyone else who is contemplating a trial and that person and their caregiver, their spouse, to just educate yourself, and get as much information as you can, ask as many questions as you can, but please don’t just throw it away out of hand. It’s definitely worth considering.
Dr. Schilsky, so we have more than 50 million people with a Hispanic background in the United States, and even if many people are speaking English they may speak Spanish at home. And then when you are diagnosed with a cancer there’s a whole new language of stuff that comes into play that even if you’re fluent in English it may not be either what you easily understand or even aligns‑‑what’s being asked of you aligns with your cultural background. Okay? So how, beyond, let’s say, the African‑American community, when you look at the Hispanic community, how do we encourage participation there and get over some of these cultural or language nuances, if you will?
Yeah. So it’s much the same thing in the sense that the same information has to be conveyed but it may have different meaning and different interpretations in different ethnic and cultural groups. Most clinical trials now will have a consent form that is fully translated into Spanish. But, of course, there are many different languages on the globe. When I was practicing at the University of Chicago for many years on the south side of Chicago, we had Polish‑speaking people, we had Russian‑speaking people, we had people‑‑Chinese‑speaking people.
So the requirements actually are that there must be a consent form, at least some reversion of which is translated into the first language of the patient. So if you’re a native Spanish speaker, a native Chinese speaker, you have to have, be able to see a consent form written in that language, and generally speaking you have to have your native language interpreter present in the room to help you go through the consent form and respond to your questions. And that person has to be someone who is independent from the research team so they can give you the straight answer and not be influenced by any member of the research team. So I think all of that certainly helps.
But, again, what helps a lot more is to have members of the care team who look like the patient. So we have problems with diversity in our profession as well. We have very few African‑American oncologists. We have more Spanish‑speaking oncologists, but again we have few Asian oncologists. So we need to do a better job of improving the diversity of our profession, improving the diversity of the care teams. We need nursing staff and research staff and other people who work with our patients who represent them and gain their trust, who look like them, who talk their language. And I think that will go a long way toward making people feel more comfortable about participating in clinical trials.
I was at a conference last week and I heard some of the patient experience, people from different drug companies talking about how they were trying to simplify their forms because I know in 2000 when I entered a Phase 2 trial there were all kinds of black boxes, you could die, you could this, everything in the kitchen sink was in it. I’m still here, and I think because of the trial, and most of the side effects I didn’t have or they were definitely handled extremely well.
So right now, where are we, Dr. Schilsky, with participation? And why is it important? In other words, in this age of personalized medicine why do we need more black people in certain trials? Like, I know in multiple myeloma, one of the areas we cover, there’s a higher incidence in the black population, right, but yet few black people are in the trials for myeloma drugs. Or maybe there are differences with Asian populations or other populations. So is it that you can’t really get a clear scientific answer on the differences? Is that it?
That’s part of it. First of all, we want anybody who could potentially benefit from being in a trial to be able to be in the trial for their own personal benefit. Secondly, we need to learn about the performance of the drug or the intervention in all the diverse populations in which it might be used. And one of the things we have learned is that not all populations respond the same way. Some treatments are more toxic in certain racial or ethnic groups. Some are more effective in some racial or ethnic groups.
And, you know, since you brought up this whole new world of precision medicine, I’ll give you the example of the lung cancer drugs that are used to treat the specific mutations in a gene called EGFR. So that’s a gene which has mutated in about 15 percent of Caucasian patients with lung cancer, but it’s mutated much more commonly in Asian patients. And in fact one of the clues that there was even a gene mutation that was important in determining whether these drugs worked or not was because it was observed that the drugs worked better in the Asian patients in the clinical trials even before the genetic abnormality had been discovered. And the clue was what’s different about the Asian patients than the other patients in the trial.
So the diversity is critical to our learning and critical to our application of the therapy in all the diverse populations that we serve.
If you’re in our viewing community and you have a question, send your questions into firstname.lastname@example.org, email@example.com. We’ll continue our discussion of course, but we invite you to join in.
So, Mel, when you get to talk to people, what do you say? Somebody is sick, diagnosed with a cancer, what do you say? Dr. Schilsky was talking about not seeing clinical trials as a last resort, and you weren’t seeing it that way (?) Inaudible, but today what would you say to people when you talk to them about it?
Well, I will say explore your possibilities because there are all different opportunities at each phase. You may not go into Phase 1 but you could do a Phase 2, 3, 4‑‑or Phase 3, and you don’t know what’s going to happen in each of those phases. So you just have to see what’s out there. And I’m exhibit A, so they look at me and they say, well, I can work, and then not as suspicious, you know. We have Tuskegee, and that was 1972, and it was that dark period of cancer history so that kind of rolls around in their mind, but you can’t let that jeopardize the opportunity such as Gleevec that I took advantage of. So we know that Gleevec worked, and there are other drugs that have improved the quality of life and the lifespan of cancer patients. So definitely research those drugs.
Did you lose heart when you were first in one trial and the medicine wasn’t working for very long? Some would say, well, all right, I tried a trial, forget about it, you know. But you then pursued other trials. What propelled you to do that?
Well, I was still in the game, so I saw that these trials took‑‑well, first of all, I could not find a bone marrow donor, but a bone marrow transplant was pretty drastic in itself so I was looking at these other opportunities as maybe not even having to take part in‑‑have a bone marrow transplant. So that was another incentive. So‑‑and I knew that if I didn’t find one‑‑there was a very small chance, there was only about 5 percent of Americas who are on the marrow registry, so basically I was helping to build a list, maybe not for myself but for people in the future who needed a transplant.
Dr. Schilsky, let’s talk about the pace of research. So, first of all, if we don’t get enough participation in trials how does that slow drug development?
Well, it slows it down enormously because we have to have a certain number of people in each trial to be able to get a reliable answer. And these days it’s becoming even more challenging because as we’re developing drugs that only target a specific genetic abnormality in the tumor which sometimes is very rare so we may be looking for a genetic abnormality that only occurs in 2 or 3 percent of all people with a certain kind of cancer. First you have to find the people who have that genetic abnormalities, then you have to be able to enroll them in a clinical trial. They have to be willing. They have to meet the enrollment criteria. So it can take a long time, and even a global effort to find enough people to fill out a clinical trial.
And most clinical trials in order to produce a reliable result are going to require a minimum of 50 to 100 patients. Some require many hundreds of patients or even many thousands of patients depending on the question being asked. So you can see if people are not participating it’s going to take long time to get those answers.
Now, Mel, you got Gleevec in a trial at least three years before it was approved, and it was approved fast because it was such a breakthrough, right? So you literally got tomorrow’s medicine today, and it saved your life in the process, right?
Yes, because I was past the three years. I was about three years and eight months in my diagnosis, so you add another three years onto that and I would not have been here.
Right. In my case I was in a trial related to chronic lymphocytic leukemia, three‑drug combination, and I received that in a Phase 2 trial 10 years before that was approved. So it was a long time.
So I have a question for you about personalized medicine, Dr. Schilsky. So for instance in chronic lymphocytic leukemia I’m not‑‑I’m Caucasian but I’m Ashkenazic Jewish, okay? So where we’re going with personalized medicine, are we beginning to find subsets among Caucasians, among African‑Americans, among Asians, where there are even more narrow slices to help us understand targeting of medicines and what’s effective for whom? Is that where we’re headed?
Absolutely. And, as I said earlier, we’re seeing that all the time. So almost every common cancer now is being broken down into a whole basketful of rare cancers under the broad umbrella of whatever the cancer type. So lung cancer, there’s probably six or eight different kinds of lung cancer now that each have a specific genetic abnormality, that each requires a specific treatment. And many of those treatments now are FDA approved, but the first thing you have to know is does the cancer have the genetic abnormality and then what is the appropriate treatment to use. We’re seeing that in breast cancer, in melanoma, in many other kinds of cancer types.
There’s another‑‑there’s a related issue here, though, of course, which is that not everybody metabolizes drugs the same way, and so another reason to have diverse populations in a clinical trial is to learn about side effect profile of the drug, learn about the right dose of the drug to use. And we know full well, for example, that African‑Americans metabolize some drugs differently from white people, and so, depending upon how the drug is working in the body, an African‑American person might require a higher dose or a lower dose of the same drug that a white person would require in order to get the same therapeutic effect.
So it just speaks to the point again where if you don’t have diverse populations in the trials you can’t learn this stuff so that doctors then have the information they need to be able to prescribe the drug in the best way for their particular patient.
Okay. Here’s some questions we’ve been getting in. Kaitlin wrote in, Mel, she wants to know, do you still participate in follow‑up activities related to the trial you were in? So tell us about your participation and sort of follow‑up.
My follow‑up is I go out to MD Anderson twice a year, and it’s just a one‑day, one‑hour doctor visit where they take the blood work and they check and see if everything’s stable. And then when I’m back home, twice a year I have my blood work checked back at home, and that’s the extent of the follow‑up. I still have to take medication, one pill a day.
Right. And is that still covered by the trial?
Well, it’s covered by the trial, but my insurance also covers it. I did Gleevec for life because of the trial.
Okay. Dr. Schilsky, let me just ask you, is that a benefit typically of trials? Like with these oral cancer medicines which you know can be so expensive, if you’re in a trial for one do you get it for life or an extended time or how does that work?
Depends a little bit on the trial and the sponsor for the trial, but the one thing for sure is when you’re on a trial whatever the investigational drug is, whatever is being researched, that’s provided for free. And any testing that would be considered to be for research purposes is provided by free‑‑for free. So that’s a benefit of participating in the trial.
Typically the drugs continue to be provided for free for as long as the patient continues to benefit. Now, sometimes if the drug ultimately gets FDA approved then it may be necessary at some time in the future for a patient to switch over from the research drug to the commercial drug, but of course at that time the drug is FDA approved and if the person has insurance it will generally be covered by their insurance.
Okay. We got a question in though for you, Dr. Schilsky, from Darrell. We were talking about genomic testing to understand what version of a disease we have either because of our ethnic background or some other thing that’s going on with us. As you know, insurance companies for a while have been balking at some of these more sophisticated tests, yet we and our doctor need that for us to get what may be right on target for us. So maybe you could talk about work that ASCO’s doing at all related to that. We want the testing done, but we also want to get it paid for so we can get that right, precise care.
Yeah. It’s a complicated question because the testing is done at different points in the person’s illness. And so typically a test on a tumor specimen that’s necessary to determine a standard of care treatment, and many of these tests are referred to as companion diagnostic tests. Those tests typically are covered by insurance because the treatments themselves are also covered by insurance and the only way to know if you can get the treatment is to have the test done.
Now, where it gets a little bit uncertain is when you get into this sort of large‑scale genomic testing where a patient’s tumor might be tested for many hundreds of genes not really knowing what you’re looking for and not really knowing what you’re going to do when you find it. And that is where you’re beginning to bump up a little bit against, research and that’s where the insurance companies, sometimes some are reluctant to pay for that kind of testing.
Now, at least one of those large genomic profiling tests earlier this year was approved by both the FDA and Medicare and now will be reimbursed. So that’s the good news, and I think that’s the direction that most insurance companies are heading in.
One of the things that my organization is doing to try to understand how best to use these tests and how best to use targeted cancer drugs is we’re doing our own clinical trial that’s available in 20 states around the country, so not the entire country yet, but has already enrolled more than 1200 people on the study over the last two and a half years. And we’re doing this study to understand how this kind of genomic testing is done, what kind of treatment is recommended based on the results of the genomic test and whether or not that treatment actually works.
Cecelia, you mentioned earlier about the lady walked into the health fair and when you started talking to her about trials she said I got to go to work, and she walked out. And Dr. Schilsky was talking about eligibility requirements, but there are other issues where the study may be asking you to come back to some place or have multiple tests with some frequency so it’s not just leaving work one time. It may be leaving work 20 times. Have you had people voice that concern to you, that it’s just‑‑what’s being requested is just too much?
Yes. I think the lack of convenience for people who don’t have the funds or don’t search out the funds would definitely hinder them being on a clinical trial or being open to hear about the clinical trial. So, yeah, convenience and awareness. We try to spread awareness that, yes, after we talk about the disease, the myeloma and the symptoms then we go into the resources. And, you know, I make sure I tell them about calling the information line and talking to the masters level oncologist professional there and finding out about the latest trials, the latest treatments in addition to what they’re doing currently with their doctors or their family members or friend that is diagnosed with one of the blood cancers.
Dr. Schilsky, she’s getting at helping people sort out what trials are available. So medical science is a moving forward, and I’m sure you as an oncologist say, hallelujah, there are more trials than ever, but it’s often not only daunting to understand any one of them but to go through a bunch of them to understand what might be right for you. So how can ASCO help that? Is it just simply educating your doctor, or what can we do for families affected by cancer so they can get at what could be a match for them?
Yeah, it’s a great question. So there are a lot of resources available, as Cecelia has mentioned. We can help patients understand and even begin to sort of, you know, wade through and winnow down the potential clinical trial options for them. One things that we’re working on and very interested in doing is sort of flipping the current paradigm by which trials are done. So right now, typically speaking, the patient has to travel to whatever site has the trial available. If they’re fortunate enough that that’s their own doctor’s office, that’s great, but, as in Mel’s case he had to travel to MD Anderson to get the trial.
The technology these days is at a point where we think we can flip that. Instead of making the patient go to the trial we’re going to work toward making the trial come to the patient. So if your doctor is aware that a trial exists somewhere in the world it should be possible for the doctor to basically just go to a website, find the research study, find the consent form, find the other documents that are necessary and present that to the patient. And if the patient qualifies just sign them up instead of making the patient travel hundreds of miles away to the one place that has the trial available.
Some trials have already gone down this road, and they’ve actually been recruiting very successfully, but it’s still not the usual way in which things are done, and we think we need to try to flip things around a little bit to make it easier for the trial to come to the patients. Let the trial travel. Let’s not make the patient travel.
That sounds great.
Can I add something to that, Andrew?
Okay. As a veteran, I was part of the VA system, and I had to go out to MD Anderson, but this summer they started something called Navigate, the VA had started something called Navigate, which partners with the NCI. And it’s at 12 sites around the country, and it’s to bring the clinical trials to the VA. It’s right there. So if it’s an NCI clinical trial then the veteran can get on that clinical trial. And there’s a lot of African‑American veterans who can take advantage of that.
For sure. That’s terrific. So we’re going in the right direction. One other thing I think that needs to change is we talked about the scientists, whether they’re federal government scientists or drug company scientists, and they want to get answers to a whole bunch of scientific questions. So they may say, as you write the protocol I think it is, well, you have to get so many CT scans and you have to get so many blood tests and stuff like that. And it can become onerous, Dr. Schilsky.
What’s happening in trial design so that, A, we talked about eligibility, you can get into the trial, but the things you’re asking of me may have logistical hurdles as well that you’re kind the lightening up on it to get to the key scientific question without all these other bells and whistles that make it tough on me.
Yes. I like to think of it as the need to know and the nice to know, right? There are certain things you need to know in the trial to be sure that the treatment is working, the patient is safe and not having any severe side effects and things of that sort. A lot of that stuff is the same stuff that doctors order every day on their patients as part of routine clinical care, and so much of what needs to be collected in clinical trials really aligns pretty well with standard of care.
Now, that said, because clinical trials are research and because there’s always new frontiers to explore, sometimes testing in a clinical trial extends beyond what the standard of care is. Sometimes patients are asked to give extra specimens of their blood, of their normal tissues, of their tumor tissues. Extra biopsies might be required, things of that sort. Patients need to understand why they’re being asked to do that, what those specimens are going to be used for, how is it going to advance research.
And, frankly, they’re very important to expanding the scope of the research. So, for example, oftentimes those specimens are used. If the treatment doesn’t work in a patient having those specimens can help the scientists understand why the treatment didn’t work, and that opens up a whole new horizon to explore to potentially make the treatment better in other patients.
Mel, do you recognize that by being in a trial and the work that you and Cecelia have been doing that you’ve probably helped thousands of patients by first being in a trial and then you and Cecelia talking about it?
Yeah. Yeah. I guess that’s kind of hard sometimes. You don’t see yourself in that role, but as I look back on it, yes.
Cecelia, you’ve probably talked to a lot of people. Have you seen a change where‑‑you’ve been doing this for a number of years where earlier on people said no, no, no. Are people more receptive? Do you see a change going on? Let’s say in the African‑American community, do you think people are a little more receptive?
Yes, I think so. I think they are more receptive, and this has a lot to do with education and awareness, and that’s what we are out there doing when we are out there in the community. And the more they hear about it and the more they read about it and the more they can see examples like Melvin, and we know one or two other people that we’ve met that were also on a clinical trial. One is in our church, and he had a type of leukemia, and we didn’t know why he was sick. But he is doing very well.
And so the more we can get those examples out there in the community of successful clinical trial patients, it really helps and goes a long way toward helping people of color relax and come aboard. And I just say, please, do your research, educate yourself and ask questions and please stay open and don’t dismiss clinical trials out of hand.
And, Andrew, if I could just add to that. I just want to make the point that it’s people like Mel who are creating the future. Everything we know about how to treat cancer we learned from the people who participated in the clinical trials. We’ve been doing clinical trials in cancer for at least 70 years, and all of the standard of care treatments that we have today came from the participation of people in clinical trials. And that’s how we make progress. That’s how we’ll continue to make progress.
So it’s the clinical trial participants who, sure, they’re in it for themselves. We understand that. They’re looking for a new treatment, a better outcome, but they are the heroes of oncology because they are paving the way, trying the course and ultimately making a better future for every cancer patient who follows them.
Amen. Let me just recap a couple of things, and correct me if I get anything wrong, either of you. So, first of all, Dr. Schilsky, I know there are more trials now than ever before, and they’re now looking at these rare subtypes as well, and so if we participate we may get the benefit of tomorrow’s benefit today. Cecelia was talking about assistance programs, people to help you sort it out, that you are noticing how there are difference among us about the ways that drugs are effective or not, and that’s so important to learn.
If we partner with you, Dr. Schilsky, and the many thousands of oncologists and researchers that you represent, can we get to the goal line faster? In other words, are you hopeful that if we really consider trials and participate in trials and stay in trials and the different groups that we can get closer to cancer cures?
Absolutely. I mean, we have more and better cancer treatments today than we’ve ever had before. We have all sorts of new and hopeful treatments on the horizon. We have to prove that they are safe and effective treatments to get them out there into routine clinical practice, and that’s where the clinical trials come in. So the more people who participate in trials the more quickly those trials can be completed and give us an answer, then the more quickly those drugs will make their way into standard clinical practice where everybody can benefit from them.
Okay. So a couple of to‑dos for our audience if you’re a patient or a loved one or however you hear this. Ask your doctor about whether trials apply to you or your loved one who is diagnosed with cancer even if it’s on day one. You don’t have to be at death’s door. You’ve been diagnosed or a diagnosis is suspected, what tests can we do, how do we know what we’re dealing with, and when we look at the treatment options is a trial a possibility if that makes sense, right?
Okay. Step two, are there resources to help me overcome any obstacles I may have to participation, first understanding the trial, understanding it in my first language, sorting out is it right for me, getting to where it is and then staying in the trial because many people, unfortunately, don’t stay in the trial and so how do be help the trial get to the goal line?
And then lastly, Dr. Schilsky, it sounds like you’re doing a lot at the community level to have more doctors have an easier time of the bureaucracy that we’ve had with trials before and the understanding of this flood of trials that’s happening, right?
Absolutely. And, you know, to be perfectly honest, the clinical trial community has‑‑we ourselves have created some of the bureaucracy, some of the excess regulation, some of the barriers to participation. It’s up to us to strip those away and solve the problem and make clinical trials more broadly available. We are working very hard now to make that happen.
Okay. So whatever community you’re in. I’m in the Ashkenazic Jewish community. Mel and Cecelia are in the African‑American community. We have people watching who are in the Hispanic community, the Asian community. If you have benefited from a trial, talk it up, right? Cecelia, people should talk it up, correct?
Exactly, yes. Please, talk it up.
Mel, thank you. I wish you really continued good health. How many years has it been since you were diagnosed?
Well, in about two months it will be 24 years.
Twenty‑four years, and for me it’s 22 years. And had there not been trials either that we were in or somebody else was in we wouldn’t be here.
So, thank you. And also, Cecelia, thank you for being a community activist when it comes to trials and being supportive of Mel as he’s been in a trial because some other people would say, you can’t go there, you can’t do this, and you’ve been supportive every step of the way. Thank you for that.
Oh, you’re so welcome. It was a pleasure to do it.
Mel and Cecelia Mann from Atlanta. And Dr. Richard Schilsky, you’ve devoted your life to this, Dr. Schilsky, and I just want to say on behalf of the cancer patient community thank you and thank you for the leadership that ASCO is trying to do, both with changing research requirements, working with government, working with industry, and you thank you personally for your devotion to us. I really appreciate you being with us.
It was my great pleasure. And, again, congratulations to Mel and Cecelia.
Okay. Thank you all. So this is what we do with our Clinical Trials Mythbusters program. Please tell others about it. The replay is available very shortly and all kinds of little highlights that we’ve done today. But what’s important is wherever you are is remember we can’t develop new medicines unless all of us work together to participate to get the scientific answers that apply to us, whatever our unique situation is, and then we can work with government to approve new medicines, get them on the market and so many people can benefit in the US and worldwide.
Thank you so much for being with us on this Patient Empowerment Network program. I’m gratified to be part of it. Thanks too to our financial supporters AbbVie, Astellas, Celgene and Novartis and their dedication to drug development and supporting and sponsoring clinical trials. I’m Andrew Schorr near San Diego. Remember, knowledge can be the best medicine of all.
Please remember the opinions expressed on Patient Empowerment Network (PEN) are not necessarily the views of our sponsors, contributors, partners or PEN. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
Actionable Advice for Knocking Down Obstacles to Trial Participation
Clinical trials offer tomorrow’s medicine today, but more often than not, only a small fraction of patients ultimately enroll in a trial due to barriers posed by financial logistics, distrust and travel, to name a few. In this MythBusters program, we will examine the barriers to enrollment, evaluate patient needs and discuss resources to help guide people through the clinical trial process with the help from two experts, Dana Dornsife of Lazarex Foundation and Myeloma Survivor Reina Weiner.
Andrew: Hello from Carlsbad, California, near San Diego. I’m Andrew Schorr from Patient Power. Welcome to today’s Patient Empowerment Network program, clinical trials myth busters and actionable advice, resources for knocking down obstacles to trial participation. I wanna thank the companies that have provided financial support for this program. They have no editorial control, but we definitely thank them for their support. Those supporters are AbbVie Incorporated, Astellas, Celgene Corporation, and Novartis.
Okay. We have a lot to talk about. First of all, I’ll just say I’ve been in two clinical trials; one Phase 2 many years ago at MD Anderson for the leukemia I have, chronic lymphocytic leukemia. And that gave me tomorrow’s medicine today. It worked, but I had travel far to do it and there were costs involved.
And then I was in a second Phase 3 trial close to home, and that was good too, and discovered another cancer that I have, myelofibrosis, through the monitoring in the trial. So, I’m a believer, but there are obstacles, and let’s talk about some of these. And we’re gonna give you some very specific resources to overcome these obstacles, so that hopefully, if a clinical trial is right for you, you can participate, you can feel good about it, and you can move medical science along to help everyone who is dealing with that condition.
So, what are some of the issues? Financial, of course; logistical issues, of course; distrust, are they really gonna take care of you or are they gonna protect your safety? Is it really right? And are you being given the straight scoop? What about travel costs? I went from Seattle to Houston, Texas a few times. Costly, okay? Stay in a hotel. It’s costly. Get a babysitter, leave work; costly.
The guinea pig syndrome; you’ve heard about it so many times. Are they gonna experiment on you, and are they really protecting you, and are you a number, or you are a person with cancer, or your loved one? And then is your medical team that you’re talking to about your treatment, are they informed about clinical trials? Or are they pooh-poohing clinical trials because they don’t wanna do the paperwork, or it’s happening down the road and not at their clinic. Lots of issues; we’ll talk about that.
Okay, I got some great helpers. So, first let’s go to Asheville, North Carolina, and you are used to live in Charlotte. Reina Weiner joins us. Reina, welcome to our program today. There we go. Say that again, Reina, you were muted.
Reina: Thank you.
Andrew: Okay. Now we should tell you that last June, well, June of 2017, Reina had a autologous transplant for multiple myeloma. And along the way, leading up to that, over many years she was in four trials. So, first of all, Reina, let’s start with what’s most important. Post-transplant, how are you feeling today?
Reina: I’m feeling very well. Thank you, Andrew.
Andrew: Okay, and what’s coming up at the beginning of September?
Reina: What is coming up at the – oh, a big party is coming up. Our children are throwing us our 50th wedding anniversary party, so that’s been cool.
Andrew: Yeah. Well, congratulations. And you’ve been dealing with what became multiple myeloma since 1999. We’re gonna come back and track that in a minute, as far as the steps along the way, the concerns you had or not at different times about being in four clinical trials.
And now let’s go up near San Francisco in the East Bay of San Francisco Bay, Danville, California. Dana Dornsife. And Dana is the Chairman of the Lazarex Cancer Foundation. Dana, thank you so much for being with us.
Dana: Thank you, Andrew.
Andrew: Okay. Now ladies and gentlemen, I want you to know Dana and her husband and her family, overall, they’re incredibly philanthropic across a number of issues that are faced globally, and also in the US. But one of them is helping people with the financial issues that prevent them from being a clinical trial. So, Dana, this is a personal story for you, so maybe you could just tell us why did you start the foundation? It was a family issue.
Dana: It was a family issue, and that family issue really revealed to me a gap that exists in cancer care for advanced-stage patients who want to remain in their battle with cancer through clinical trial participation. My youngest sister’s husband, Mike, was diagnosed with pancreatic cancer in his early 40s. He was given one half of one percent chance to live, and at the time 35,000 people a year were diagnosed, and 35,000 people a year were dying from pancreatic cancer.
So, we decided as a family that if Mike wanted different results that we would need to do something different. And Mike and Erin went ahead and pursued standard of care, and I was tasked with identifying clinical trial opportunities for Mike. And, of course, that sounds very linear, but in fact, for a layperson it was a very difficult task to undertake. I did identify some trial opportunities for Mike. He did participate in a trial and responded well for a period of time, he had good quality of life.
And during that period of time he was meeting people who were asking him, “Hey, what are you doing? I wanna do what you’re doing.” And he would say to them, “Oh, just call my sister-in-law, Dana. She’ll help you.” And that’s literally how this organization began. Through those phone calls that I was receiving from other pancreatic cancer patients, I began to understand that Mike was able to take advantage of medical breakthroughs in clinical trials because he had a family who could afford to support him through the process. And all of these other families that I was talking to, they just didn’t have the financial wherewithal.
So, we started Lazarex in order to fill that gap and help people identify clinical trial opportunities, and then provide financial assistance to them to help cover the out-of-pocket expenses that create huge barriers for patients who are already experiencing financial toxicity due to their disease.
Andrew: Well, thank you for what you do. And we’re gonna talk a lot along the way about resources. There’s a downloadable guide that you’ll be provided with, along with a link to the replay of this program. And that’s gonna have specific resources that you can access, whether it’s financial issues, other issues you may be facing. So, look for that.
Today we’re really focused on actionable resources. So, let’s go to Reina for second. So, Reina, you had been in the pharmaceutical industry.
Reina: Yes, I had.
Andrew: So, you knew about drug development, and you understood about clinical trials. So, I’m willing to bet you were pretty proactive. People who weren’t in the field, they don’t know from clinical trials, and maybe they’d been worried about it. They’ve worried would they be experimented on, would they be a number and not name, would they get quality care. But you were probably, I have a feeling, pretty proactive. And you write about that. I know you have a book as well. So, is that Step 1 for people to speak up for themselves?
Reina: It is Step 1; absolutely, Step 1. And what I found is, first of all, people don’t know about trials. And if you go to a small community practice where they’re very busy, they don’t have the time, they don’t have the staff to really educate patients about trials, the best, best step for patients to take is to ask, “Is there a clinical trial that might be appropriate for me?” That’s huge.
Even when I went to a very well respected hospital and there was a researcher who was following me as I had smoldering myeloma and the numbers kept going up and up and up. I said is there – because I was living close to the NCI – is there a trial that would be appropriate to me at the NCI. And he said just a minute, turned around, went to his computer, found the trial and that’s how I got in.
Andrew: But it wasn’t at where you were receiving care or being monitored at that time. It was somewhere else.
Reina: It was not. It was at somewhere else.
Andrew: Okay. Dana, is one of the obstacles, not just financial, or maybe it’s even the business of cancer where if an oncology practice that you’re going to that’s maybe close to home is not doing the trial, maybe it’s not even in their financial interests to tell you. I mean, is there an awareness issue, do you feel?
Dana: There’s a huge awareness issue there, Andrew. And it all starts with knowledge is power, right, so I completely agreement with Reina’s comment about one of the first questions you need to ask is, is there a clinical trial out there for me because many doctors who are in community environments don’t offer that information. It’s not what they do every day. They’re there to administer standard of care. Only 6 percent of doctors actually engage in conversation with their patients about clinical trials, and that’s usually the 6 percent who are associated with research universities, right?
So, knowledge is power. If the patient doesn’t know about a clinical trial, they’re never going to participate. But once you find out and once you’ve identified an opportunity, the second biggest hurdle is that out-of-pocket expenses associated because most patients have been dealing with their disease for a longer period of time, and they’re basically broken in every way: physically, emotionally, spiritually, and, sadly, financially.
So, patients start to make decisions about the outcome of their care based on the size of their checkbook, and not focused on what’s best for them. And so, Lazarex eliminates that financial barrier as well to help patients say, “Yes, I can participate,” and we can get them where they need to be when they need to be there.
And that’s just the tip of the iceberg, Andrew, because there are many other barriers that exist; socioeconomic barriers, language, culture, historical barriers. And we are tackling all of those barriers one at a time. But really, the biggest two barriers are knowledge and financial.
Andrew: Right. And you mentioned about the historical barriers. Some people know about the Tuskegee experiments with African-American people, so in the African-American community, there still is a distrust among some people. Yet if you think about it from the FDA’s point of view where a company that’s developing a drug, or the NIH, they say okay, how does it work on broader populations or different ethnic groups or different ages or genders, et cetera?
They want to understand that data, and so not just having a number of people participating in the trial, but having it reach people who are in different situations, if you will. And so –
Reina: And if I may – ooh, I’m sorry.
Andrew: Reina, please, go ahead.
Reina: Well, if I may say that because people don’t know about it and the trials, the best trials, are trials with a variety of patients, but they do try to accrue populations who are certain ages, certain genders, ethnic groups, whatever they can get. And only 3 to 5 percent of patients participate, cancer patients, participate in clinical trials, and so much is lost if people don’t participate.
Andrew: Here in San Diego it’s sort of a pocket of a lot of medical research. There’s a lot up in your area, Dana, in the Bay Area, San Francisco Bay Area. I mean, it’s in North Carolina in the research triangle where that’s home state for Reina. And not to disclude others, and then certainly up around Boston. There are like companies all over the place and many of them are in earlier drug developments.
So, when you talk about immuno-oncology now, can we harness our immune system with the help of some medicine to fight the cancer, and I know some people who’ve received it; lung cancer patients who are living, et cetera, melanoma patients who are living for an extended time. These companies can’t move forward unless there’re people who are in the trials. So, the FDA says where’s your data? And they’re saying well, we’re trying, but we haven’t been able to complete this trial. Right, Dana? So, we can’t move towards cures unless we all come together.
Dana: That’s exactly right. So, let me just throw a few statistics out at you that I found astounding when I learned of them. So, we have a 48 percent failure rate of clinical trials, and it’s not because the drug didn’t work. We will never know, quite frankly, if the drug would have worked or not. And we will never know because there weren’t enough patients enrolled in the trials to find out.
So, 11 percent of trials never enroll a single patient, if you can believe that. So, here we are with an almost 50 percent failure rate, and yet we have 600,000 patients a year in this country who are dying from cancer. So, there’s this incredible disconnect between the thousands of patients who would participate in clinical trials if they could, and the thousands of clinical trials that need patients to participate in order to succeed. And without successfully completing those trials, those drugs are never going to get market to help the cancer patients that they are intended to serve and help.
That’s why Lazarex Cancer Foundation exists, and that’s why removing the barriers to clinical trials is so important. Our process does not lend itself well to that. And I just want to take a step back, Andrew, to address the minority participation in clinical trials. We all understand because of epigenetics and, yeah, advances in medical science that we need to have the full spectrum of our population participating in clinical trials. But that doesn’t happen. When you look at the 5 percent of patients who actually participate and you break it down ethnically and racially, less than 5 percent are from minority communities combined.
So, in theory, though we say we understand the importance of that, we’re actually not in practice doing what needs to be done. And so a lot of our work is also focused on reaching out to those socioeconomically challenged and racial and ethnic minority communities to raise awareness and help people like you’re doing on this program dispel the myths around clinical trials, so that they’re more inclined to ask better questions.
Andrew: Right. So, so important, and I applaud for that work. We’re gonna talk about the financial process in a second. Reina, so you were involved in a National Institutes of Health or National Cancer Institute trial.
Andrew: A couple of them, I think, and one at Memorial Sloan Kettering in New York’s premier resources. So, we talked about your tip was you gotta speak up and ask about trials, where they’re at that center, wherever you are, by XYZ oncology in a suburban area, whatever it is or not. So, what’s Step 2? So, for instance, now I understand there are people – and Dana, I’d like your comment on it too.
At some clinics now where there are clinical trial – there are nurse navigators, but often sometimes there are clinical trial navigators too, but often you gotta ask about that too, right, Reina? I mean, it’s speaking up and looking for the resources that are available to you there or wherever you choose to go, right?
Dana: Yes, and there are organizations like Dana’s who help people do clinical trial searches because that’s a bit overwhelming when you are already frightened, you already have the financial issues coming up. And like you mentioned, logistical issues. So, there is Dana’s organization; therefore, myeloma, the SparkCures. There’s the MMRF. There’s the International Myeloma Foundation. There is something called Cis Crypt. And so, they will help you find a trial.
And there are lots of regional trials groups, so you may not need to go to the big, big research center. They might be able to do it locally for you. But I always want to bring up the fact that there’s so much misinformation about trials and what it entails. There’s a tremendous amount of fear. And when I went on the first trial, as I wrote about a little blog recently, everybody said to my husband – well, not everybody, but an awful lot of people said why would you let your wife going in a clinical trial? She’s definitely gonna be a guinea pig.
And I can tell you very, very, very clearly that you get so much care. There’s so much documentation. And the patient’s health is never sacrificed for the research ever. And so, and you sign a consent form, so you’re very clear about what is going to happen. And yes, there’s more there’s more bloodwork. Yes, there are more biopsies. And it’s part of research. And when you sign up, you sign up. And I had more than I’d like to even talk about, but I feel very grateful and very humbled for the care that I received.
And I can tell you, too, that I talked to other people on the trial. And yes, they hope to gain better control of their cancer. But, in addition, they really hope to help the next group of patients who are coming up, so that these new treatments actually happen.
Andrew: I feel the same way. I was in a trial at MD Anderson in 2000, and the three-drug combination I got was not approved till ten years later, but they learned a lot. And you were on a three-drug combination, which I think still has not been approved for first line, but it’s is widely used, I think.
Andrew: So, in multiple myeloma. I wanted to mention some other resources, the Leukemia & Lymphoma Society also has a resource center. You can call them. So, there’re these different groups that help you identify a trial, and doctors who specialize, so let’s say pancreatic cancer, you mentioned earlier Dana. I got a call from a friend in Miami, “How do I find a pancreatic cancer specialist?” And I connected them with PanCAN, Pancreatic Cancer Action Network in Los Angeles, who knows who are the doctors who have the most experience with that.
Now, Dana, so then the next thing comes up is alright, I’ve identified the trial, but it’s not where I am. So, now we talk about logistics and finance. So, let’s say somebody calls your foundation. Tell us how it works. So, I don’t have the resources. Maybe they live in Northern California and the trial is in Southern California or in Salt Lake City. What happens next?
Dana: So, Andrew, in some cases it’s not even that distance. In some cases it’s getting from Sacramento to San Francisco, which is literally a one hour, one-and-a-half hours without traffic, in your car. And sometimes it’s a tank of gas, a bridge toll, and parking. I mean, we’re not talking about thousands of dollars in some cases, but it’s still the difference between life and death.
When someone calls Lazarex Cancer Foundation, they can contact us directly. We have a financial application that we use to determine the degree of eligibility for patients to get their out-of-pocket expenses reimbursed. Or they can be referred to us by their social worker at the institution where they are receiving, or thinking about participating in a clinical trial.
We take a look at the household income of the patient, and I believe our guidelines are very generous. We go up to seven times the federal poverty guidelines for patients. And we arrived at that number through trial and error. Our goal is to help as many patients as possible participate in clinical trials, and turn away as few as possible. And then we reimburse on a sliding scale from 100 percent to 75 percent to 50 percent depending upon your household income.
And it’s a pretty easy process to go through in order to be enrolled and receive the reimbursement. And then we reimburse our patients monthly, on a monthly basis. And in some cases, we’ve been working with patients, we follow them, like Reina, through two, three, four clinical trials. And we’ve been supporting them in trials for years. And without doing what we do, they may not be here with us today.
Andrew: Well, I’m sure you’ve saved some lives and lengthened some lives. Reina, so you were in the pharmaceutical industry and in oncology, I believe, before all of this started happening to you. And you’ve continued teaching nurses and devoting yourself to education and your book and your blogs. Thank you for all that. Maybe that’s what life’s about.
But knowing on the inside there are pharmaceutical programs, in some cases, I think, particularly for rare cancers where they may provide assistance. They can’t pay you to be in the trial, but there are at times assistance and travel logistics, particularly for rare cancers where maybe the trial is not, not one hour away. Am I right, Reina? Are you familiar?
Reina: Oh, there are. And sometimes when I was working, there would be a patient who had a cancer that really was not aligned with a particular treatment that would be effective for them. And so, the doctor wanted to try an off-label use of a product, and so then they would come to me and asked me if I could get the pharmaceutical company to provide the drug for free.
And sometimes it takes a little doing, but I was concerned about the patient and hoping to get them a better quality of life, if not an extended period of life. And so, yeah, the company would do that. Not every day, not all the time, but if the company had evidence that this was a patient who would benefit from the off-label use of a product then they would help them out.
Andrew: Okay. So, Dana, related to other organizations providing assistance, and I recently interviewed someone from the Family Reach Foundation where they help with rent or things, groceries, things like that. So, somebody says, “Oh my God, I’m afraid of a trial, I can’t go there,” or if they hear about it and they say, “Hmm, well, maybe I could, but I’d have to leave work, or maybe my spouse would have to leave work, we’d have to find somebody to pick up the kids from school, oh my God.” There are organizations that can help with some of these family processes, aren’t there?
Dana: Absolutely. And I think we’ve provided the Patient Empowerment Network with a list of those. 21st Century C.A.R.E. is an organization that provides patients with immediate financial assistance for expenses related to active cancer treatments. Cancer Care provides assistance for cancer-related costs. There’s a Cancer Care Co-Payment Assistance Foundation. We get that question a lot.
We’ll help with the out-of-pocket travel expenses, and in fact, some of the medical and diagnostic expenses that aren’t covered by insurance. When you’re participating in a trial, sometimes you have to get more stems than insurance will cover or whatever. But co-pays are a big deal for people to be able to afford those, and so, that is another organization that can help. Patient Advocate Foundation, which is an underinsured resource directory.
So, there are a lot of you nonprofits out there who exist to support patients through the fifth process. It’s just a matter of helping patients really understand and put together all of those resources in a way that they can access them.
Andrew: Okay. So, Reina, you’ve been through it four times, and you’re a pretty savvy person. Not all of us know as much, so help us now. So, one of the questions in a trial is, and in cancer, am I gonna get what I describe as the good stuff, knowing that the good stuff that’s being tried may not be good. I mean, it may not work out. There are trials that go bust. Not just for not getting people, but they got people, but it wasn’t as effective as they hoped it would be.
But let’s say we’ve done our homework and we go to a certain clinic, but it’s some sorta controlled trial. We don’t know whether we’ll be in the arm. So, was a concern for you? Were you gonna get the good stuff, and why do it?
Reina: Well, no, really, Andrew, because I know that like if it’s a Phase 3 trial, so you’re comparing standard of care versus the newest and hopefully the latest and greatest. If it turns out that one arm of the trial really shows a significant improvement, patients are always switched to the more effective arm of the trial. They don’t leave you on this arm of the trial thinking well, what the heck, we’ll just leave you there and see how the research pans out. So, they are always switched over to the most effective.
So, I wasn’t really concerned about that. And in the Phase 2 trial, it’s just seeing if the product was effective. And so, that was obviously not a concern for me. So, it worked out, and I do think, though, like what Dana does is absolutely wonderful at totally, totally, totally past wonderful.
But I always try to let people know who have friends and family who are facing some chronic significant illness that don’t just call and say let me know, let me know if I can help you because that’s so ambiguous. And most people will not call because they have pride or they think they can do it all by themselves.
So, I always try to suggest to people that if you’re calling somebody who you think might need some help, be specific. Call and say, “Can I walk the dog? I’m going to the grocery store in an hour. Is there something I can pick up for you? Can I mow the grass?” Anything that will help, but make sure that you are specific in your offering.
Andrew: I want to talk about a related issue. You use the word pride. Some people, maybe in some cases it’s even shame. They developed a certain cancer. Where these are maybe middle-class people who’ve had some resources. They’ve been paying their mortgage. They’ve been paying their expenses, making do. But now they get hit with a cancer diagnosis, which is catastrophic, and there is help available, Dana, but they’re too proud to ask for it when this could happen to anybody. And maybe you’ve even countered that along the way or know there’re people out there. What would you say to people, to not be shamed and to speak up?
Dana: Yeah. Well, sadly, one in three women will be diagnosed with cancer, and one in two men. And so, this is not an uncommon scenario, right? The likelihood of knowing someone who will receive a cancer diagnosis is very likely. So, I think that patients have to understand that pride doesn’t help you in your process with battling this disease. You have to take advantage of every opportunity that’s out there in order to come out on the positive side of this experience. And if you don’t take advantage of every opportunity, you may not.
And so, it’s one of those things that we just have to deal with right from the beginning, and just say okay, again, knowledge is power. I’m going to surround myself or engage with the people that are around me who want to help me. And you have to put that team together because you will need your team with this disease.
Andrew: Okay, so great advice. Reina, part of your team maybe could be the first doctor you saw who gave you the diagnosis, but they might not be the one where a trial was offered. So, first step is you talked about speaking up, but it takes a lot of courage to say to the doctor in the white coat with all the letters after their name, you know, thank you so much, Doctor, and I’ve either found out about a trial, or your turned and typed it in somewhere else. I hope you don’t mind, but I am going to go over there. Maybe you can advise me along the way.
But that takes courage because people are terrified, and they may be bold in principal in that situation with the person in the white coat. What advice would you give?
Reina: Ooh, well, that’s a big one for a lot of people. And, really, you know what, I imagined that it would be people who are older, who come from a generation where the doctor has the final word. But what I found out when I was writing my third book is that there were younger people who also feel very uncomfortable speaking up, asking a doctor, and so forth. But really, what to really put in your little mind and in your heart is this your life.
This is not just kind of a trip to the mall. This is really important for you to either improve the quality of your life or extend the quality of life, so take a deep breath, be very polite, and I think most doctors who are professional and open-minded will hear what you have to say if you present it in a way that they can hear. And if they really don’t hear you then it might be time to have a look around to see who will.
And, really, the bottom line is you need to trust yourself. And if you feel that this is really right, that there is a clinical trial that you would be eligible for and you can participate in with Dana’s help, with the financial, with the logistics, and so forth. Like I said, you just take a deep breath. And most doctors, like I said, really want the best for you.
Andrew: Okay, let’s talk about something that comes up. One of the things for people is the criteria of different trials. Dana, I don’t know if this is in your area, too, related to financial, but people let’s say okay, I wanna be in a trial, but the criteria are so narrow that I really wanna be in the trial, but they say I can’t.
Dana: Yeah, so that is a sad reality in many cases. And I refer to this as Clinical Trial Nirvana Syndrome where as a drug sponsor for trial, you want to attract the healthiest patients you can to participate in your trial, so that you have the greatest chance of success. But, unfortunately, in many instances, in most instances, a cancer diagnosis is accompanied by other comorbidities like heart disease or diabetes or other maladies that would preclude a patient from being able to participate in a trial.
So, that is an area that we are looking into and trying to – we have several proposals out there with various aspects of our government to try and really take a closer look at that, to try and make the trial makeup in relation to patient participants better mirror the realities of our situation because the likelihood of someone, if the drug gets approved, taking that drug and having a comorbidity is pretty likely.
And yet we won’t know what will happen there, right. So, we have to drill down on these issues and it’s a great, great issue to bring up. So, we’ve got a lot of work to do ahead of us.
Andrew: Right. And another thing that comes up too, and Kevin sent in a question. Kevin, thank you for this, matching what’s available in clinical trials to where you are in your journey with an illness. So, on Day 1 you’re diagnosed. I know Esther and I, we were crying and almost on the floor. And I thought I would be dead the next day. And it really took a while to overcome the terror of the diagnosis. And so, we were not even – well, the doctor wasn’t talking about trials; we wouldn’t have been hearing it anyway.
And some of us, thank God, with some trials, with some cancers now, are blessed with living longer and we start to learn. And then we want to know, in our situation, what applies to us. So, I know there are a lot of efforts being made to match trial offerings to where you are and what you might need to know now, what might need to be offering.
And some of you have heard this term, artificial intelligence, where we in the Internet business are all trying to fine tune what we’re suggesting or putting in front of you based on who you are and where you are, recognizing privacy and all those kinda things to make it more manageable.
We still have a long way to go. I mean, we have clinicaltrials.gov, but it’s not tied to where I am, who I am, where I am in my journey. It’s just what’s being done in a certain illness, right, Reina?
Andrew: So, we have to refine our tools.
Andrew: We have to refine our tools. Well, we’ve been getting in a number of questions. So, here’s one. So, David; so, he says as the excessive use of CT scans in clinical practice moves away from being the norm, have they lessened their use in clinical trials? In other words, this is about testing, and maybe it’s about the requirements.
Dana, I don’t know if you have feelings about it, but the scientists who are doing these trials, they wanna know everything. They would like to test us. So, the CT scan, and I mean I’m gonna have one next week, but it has radiation, right?
Andrew: So, let’s do a bunch of CT scans. No, let’s do a bunch of bone marrow biopsies. No. So, I’m saying I’m sorry. Not just do I have to pay something for these tests, or is there a co-pay or whatever, but also am I gonna be radiated? Am I gonna be poked? So, what about those issues? Is there dialogue going on, not just to help us financially, but also make it less onerous, I guess?
Dana: Yes, in fact there is dialogue going on about that, and it’s good, heartfelt dialogue. And it’s coming from a myriad of stakeholders, right, not just from patient advocacy organizations, but also from within industry insurers. And the whole goal is to okay, let’s stop looking at patients as a chart or a number on a piece of paper, and let’s understand that these are living, breathing human beings who are voluntarily participating in this clinical trial process for the benefit of not only themselves, but future patients to come and our industry.
And let’s start treating patients as humans who are participating, and let’s see what we can do to lessen the number of visits or minimize the number of scans and blood work, et cetera. So, there is active dialogue around that, and I think there’s a much higher degree of sensitivity on behalf of the teams who are actually putting the protocols together now.
Andrew: All right, I think so. And I know in some cases they’re doing what’s called trial simulations with a panel of patients and saying okay, we’re trying to answer these scientific questions and see if this drug that’s in development can do better for patients and would require so many office visits. Or so many, you come to the site, but so many could be done, maybe with your local doctor if that’s closer to home. So many blood tests, so many CT scans, so many biopsies. Imagine lung cancer patients with another lung biopsy. Not fun, and often not available.
So, there are all these kind of questions. And I think that’s going on although it needs to happen more. Now Dana, do you talk to the pharmaceutical industry? We had a question from Vi Life wanting to know related to trial awareness. Beyond the financial, do you work with pharmaceutical companies at all, as you are now, today? I mean, what we’re doing here is just to raise awareness about trials or other programs that you may do.
Dana: So, we are engaging with pharma right now. We were very fortunate to work with the FDA earlier this year in securing language around reimbursement of patients’ out-of-pocket expenses associated with clinical trials. There was some very nebulous language out there that was really preventing pharma from being able to support programs like ours.
And what we’re doing now is, in addition to we’re bridging this gap for patients that exist every day by reimbursing patients, but that is not a sustainable business model. It’s noble, but we have to have our tin cup out every day. And the number of patients we can help is directly related to the amount of money that we have in our account, right?
So, in addition to that program, our Lazarex Care Program, what we are also doing is trying to fix this problem and do it in a sustainable way. And in order to do that, we actually have to shift the burden from the patient back into industry, right, and help industry understand why they should include these out-of-pocket expenses as part of the clinical trial protocol every time, right, so they can enroll trials on time, on budget, save R&D dollars, preserve patent years, right?
I mean, there are a lot of reasons why pharma would want to participate in a program like that, in addition to the fact that it’s the right thing to do, right? And then we get more drugs to market faster, and we provide a platform of equitable access for everyone. So, we are engaging pharma in discussions right now about funding this program, we call Lazarex our IMPACT Program, that’s being rolled out at comprehensive cancer centers across the country. And it stands for Improving Patient Access to Cancer Clinical Trials.
It has been received very well and I’m happy to say that Amgen actually stepped up and funded this, so we are rolling it out here in California, and we are hoping that we’ll have similar opportunities in a couple of other areas in the United States. So, they are interested, and they want to improve clinical trial enrollment retention, and especially minority participation.
Andrew: Right. Boy, that you. Again, I keep saying thank you for what you’re doing, but you’re a real leader in the field. I’m going back next month to the Biden Cancer Initiative Summit continued by Vice President, Biden, former Vice President Biden, and his wife who continue to do leadership in this. And there’ll be a lot of senior people there and I’m hoping we can talk. And I know this issue of how can we advance cancer care through research in partnership with patients is a big one. So, Dana, thank you for helping lead the way in getting this going. And thanks to Amgen just as an example.
Reina, so, we talked about the cultural differences of people being in trials. We talked about the pride people may have in asking for assistance, the fear people have maybe participating in trials. You still have a – not now. I mean, you’re doing so well and you’ve been through trials and it’s worked out well. But there must have been some bumps along the way. Were there any misgivings at different times? And if so, how did you overcome it?
Reina: Oh, yeah. Well, there were definitely misgivings, I am sure. The first trial was when I asked the doctor if there’s something going on at the NCI. And there was no misgivings about that because that was a very observational trial. The second trial was much more progressive and I felt kind of a little uncertain about it, and so I asked the researcher at this well-known institution if I should participate because the trial, I should back up a little bit, that was for either smoldering myeloma patients or active disease patients.
At the time I was smoldering, and most physicians didn’t believe that that was a good idea to treat smoldering and wait until it became active. So, I asked this one researcher and he said absolutely, not, do not participate in the trial. And then I called someone else also from a very respected institution where I had been, and he said well, if you join that trial you’ll be crossing the Rubicon, which I didn’t even know what the Rubicon was at the time. I had to go look it up.
But, basically, once you start treatment, you kind of go on that journey and there’s no way to step off. But then I thought about it, I thought about it, thought about it, and finally I decided to trust myself because I had been to the NCI. I felt very safe there. And I decided to move ahead with it.
So, yes, I had plenty of misgivings about that. The other trials, not really because that trial changed my life and it gave me a very reasonable complete response. And the other ones, like I said, they just kinda fell in with the collecting a good amount of stem cells for a transplant and so forth.
Andrew: I wanna talk about family issues. So, the decision to be in a trial affects the family, whether it’s somebody’s driving you to the doctor, somebody’s taking off work, their worry, how they feel about trials, their own view of it, family logistics, costs, et cetera. We’ve talked about that. So, you wrote this blog about people questioning your husband, I guess, was your wife gonna be in a trial? So, how did you overcome that, whether if not with your husband, just with your community that you weren’t like crazy?
Reina: Well, they already know I’m crazy, so that’s a total aside. But, really, trying to educate people about the misinformation about trials; say, look, I will never be a guinea pig because that’s not what trials are about. And it’s very well controlled and there’s a lot of data that follows you. The care that I got was excellent.
And I try to dispel, like I said, a lot of the myths; that you signed consent form, which clearly explains what the trial is about, what your commitment to it is, and you can also drop out for any reason. There was hope that you don’t because they would like to have some results that then will lead into future treatments for patients. But you can drop out, so, really, taking that opportunity to educate people about what a clinical trial is like and that there are no guinea pigs.
Andrew: I wanna just – oh, yes, please, Dana.
Dana: Yeah, if I could just offer something in that regard. For people who haven’t gone down this path, the journey with cancer, having a cancer diagnosis is not like other chronic diseases, right, like diabetes, for instance, that you can typically control with insulin or whatever, right? For a cancer patient who has failed standard of care, who’s gone through maybe second- or third-line treatment options, but still has progressive disease, that patient will die if they don’t do something, right?
And so, clinical trials offer tomorrow cures today in some instances, right, and we don’t always have positive results in clinical trials. But for a patient who’s at that crossroad where their doctor has delivered those words, “You need to get your affairs in order,” right, it’s not a matter of am I crazy if I participate in a clinical trial. What it is a matter of is do I wanna live? And if so, what clinical trial can I participate in? It’s a very different decision tree.
Andrew: Right. And I certainly say that all the time. I got a call, as I mentioned, from a friend in Miami. The mother has a very serious cancer. And I said part of the initial discussion, even the initial discussion, Dana, can also be are there clinical trials that we should consider along with standard therapy? So, certainly, if you’ve failed or they’ve failed you, the treatments no longer work, what is the 360 degree view? And if you don’t do it here, so they do it down the road, or do they do it across the country? And what are the issues for you participating?
So, a lot of thinking, but it’s gotta be part of the discussion. So, so sadly now, what are we seeing; 3 percent, 4 percent, 5 percent of adults participating in cancer clinical trials in the US. Not good at all. And are we hurting ourselves with the chance of future therapies that can be more effective, or even cures because some of these companies sometimes are venture-backed. They don’t have money forever, you know, and they’re trying to get to the goal line to go the FDA.
Look, here is another question we got in. Tamara, our producer, just sent in. She says well, what happens when you join a clinical trial and it doesn’t have a beneficial impact? So, Reina, they didn’t know that the trials would necessarily work out for you. So, what happens then? Do you go on another trial? What do you do?
Reina: Well, if it doesn’t and you don’t seem to be responding to the therapy on the trial, or you find it intolerable yourself, then they will always return you to your oncologist who you had been seeing previously. But, on the other hand, they may offer you another trial that’s available that you would be eligible for as well. So, I mean, I really try to stress to people that the researchers are looking out for you. They want the best income, in addition to accruing the data that they hope.
And I can tell you that when I was on a trial at the National Cancer Institute, when I had questions, especially about the trial with smoldering versus active disease for myeloma, they would spend a couple of hours for me, explained with me, can I say that, right? Yes, spent a couple hours with me explaining all of the aspects of the trial, so yeah.
Andrew: I wanna point up an example that some people have heard of a woman I’ve become friendly with in the myeloma community, Reina. Cherie Rineker. So, Cherie’s down in Houston, and she was dying of myeloma. And she’d been in trials and treatments. She was at MD Anderson. Bob Orlowski is one of the top doctors in the world, and her doctor. And she was in different trials and then things were not working.
And she was put in touch with another researcher doing this CAR T investigation for multiple myeloma, which is pretty new, pretty new. And they’re learning a lot. It’s not a slam dunk, but so far it’s worked for her. It saved her life. She went to Nashville, Tennessee from Houston where she lives, and maybe I’m not sure the financial issues, Dana, about going. But that’s where she’d been in successive trials. And some were not working or no longer were working. There was another approach.
I wanna ask about another concept I’ve heard called siteless trials. And I don’t know, Dana, you’re nodding your head. Maybe you are familiar with this. One is a siteless trial because we talked about these trials going on at these academic medical centers, but not much elsewhere.
Dana: So, I have tell you, I don’t have a lot of experience with siteless trials, but there is a lot of dialogue taking place around rather than having the patient go to the trial, bringing the trial to the patient, and I think that’s the impetus behind a siteless clinical trial.
I think cancer has some unique challenges, especially blood-based cancers in clinical trials, and the oversight of patients participating in those trials that make siteless trials a bit of a challenge. But I think the place to start is in other diseases, or perhaps where you have a cancer diagnosis that’s not a rare form of cancer, whatever that requires, a high degree of oversight.
But the whole goal in doing this is to understand how we can get more people into these trials and make it less obtrusive on their life, right, so that more patients would be inclined to participate, increase our enrollment retention, our minority participation, and, ultimately, reduce the burden on the patient to participate.
Andrew: Esther and I’ve given a lot of talks at different conferences, and we said you have to see patients who might be considering or are in a trial as investors. So, they’re gonna invest with their body, their time, sacrifices, and other things in their lives for the hope of being cured if they could, or doing better.
And there needs to be the communication, financial support, logistical support in really treating people with a lot of respect as a person. Reina, do you agree with that, that we have to get to that concept where we’re taken care of? And you felt that way, but we need to do it for more people and have more people feel confident that it’ll work out that way.
Reina: Oh, certainly. Certainly, I do. And the education is really essential. And after I was in the first trial, I talked to everybody who would listen to me. And even if they didn’t, I would talk anyway just to try to say this is a place where you can go where you will receive what is hopefully the newest and the best treatment that’s available. That you will be cared for as well as you can possibly be, and that everything is documented. You know all the options that you have staying on the trial, giving consent, making sure you have all the information that you need to feel comfortable.
And Dana’s organization, hopefully, helping people out financially and logistically. There are ways to get into trials that at times are very successful. For me personally, I don’t know that I would be alive now if I had been on that trial, and that’s really my claim to fame, what can I say?
Andrew: And, Reina, I would say the same thing. Had I not been in a Phase 2 trial for chronic lymphocytic leukemia in 2000, I wouldn’t be around to have had retreatment last year, which has work quite well; 17-year remission. And I wouldn’t have been able to do this, and really have a purpose in life. So, I’m very grateful for being in the trial.
Dana, I can’t tell you – we were talking about gratitude, for you; came up in your family. You saw the gap for, not so much your family, but so many other families. The issues, financial issues, and you’ve been very philanthropic and, obviously, trying to have leadership in getting at some of these – we have a very imperfect system right now, so we have a long way to go. But for our viewers, if you’re living with cancer now, if your loved one is living with cancer, there are resources, people like Lazarex, people have been through it, like Reina.
We’re gonna give you this downloadable guide. And you’re gonna connect with these resources. Don’t… Put your pride away. Dana said it so well. There’s a very high likelihood we’re gonna be affected by cancer in our families, and there is help to navigate what’s kinda complicated right now, but is doable and can offer you the chance of doing better. Dana, did I say it right?
Dana: You did. You did. You did a great job, Andrew. Thanks.
Andrew: Okay. Well, thank you. And thanks to the Lazarex Cancer Foundation and, really, all you’re doing. And let’s hope that we can improve this process, increase participation, and have so many of these companies and the government that are trying to get scientific answers. We participate as respected patient investors. And we do better well. Reina, any final words from you with your 50th wedding anniversary coming up?
Reina: I’m very grateful. I’m very grateful to be here. I’m grateful for all the clinical trials, all the physicians who have taken care of me and who listened to all my concerns and fears. And I am super-duper grateful to my husband who has supported me, helped me, been there, been my caregiver, and washed the food for me when I had the transplant, and really, all the people who have been on the journey with me. So, if you are considering a clinical trial, if there is one that you might be eligible for, give it some thought. It’s a really important choice for you to make.
Andrew: Reina, thank you so much, all the best. Happy anniversary, early. Dana, best to you. Dana Dornsife, joining us from the Lazarex Cancer Foundation in the San Francisco Bay area. Dana, good health to your family, and thank you for all you do. Thanks for being with us, Dana.
Dana: Thank you.
Andrew: And, Reina, all the best, and thank you for those great words of wisdom. And we’ll meet in person sometime and I’ll give you a big hug, okay?
Reina: I hope so. I hope so. You take care of yourself, Andrew. Thank you so much.
Andrew: Thank you for joining us for this Patient Empowerment Network program Clinical Trials Mythbusters. We hope to do more. I wanna thank the companies that have helped provide funding for it; Abbvie Incorporated, Astellas, Celgene, and Novartis, for their support.
Thank you for joining us. I’m Andrew Schorr from Patient Power down near San Diego. Remember, knowledge can be the best medicine of all.
If each of us humans is a snowflake, unique in our genomic makeup, where’s my snowflake medicine? I asked that question from the platform at the ePharma Summit in New York in 2013, and have yet to get an answer. The challenge for the bioscience industry is, I believe, the classic randomized clinical trial. That design goes through four phases:
- Phase 1: a small group of people are given the drug under study evaluate its safety, determine a safe dosage range, and identify side effects
- Phase 2: a larger group is given the drug to evaluate its efficacy and safety in a larger population
- Phase 3: large groups – plural – of people are given the drug to confirm its effectiveness, monitor side effects, compare it to other commonly-used treatments, and collect information that will allow the drug /treatment to be used safely
- Phase 4: the drug is marketed while study continues to assess long-term effects and efficacy
Of course, before they even get to Phase 1, there have to be both the idea for the new treatment, and animal studies to determine what the substance or compound under study might do to a mouse or a monkey.
Science isn’t easy. The phrase “trial and error” came out of science labs, with many trials running up against the error wall by Phase 2. Since bioscience companies can sink about $1 billion-with-a-B into getting just one drug to market, it seems that the traditional clinical trial has turned into a pathway to NOT making scientific discoveries that can benefit humankind.
Then there’s the whole “who’s in charge here?” question. Clinical trials are now a global effort, with US and European pharma companies testing new treatments in Latin America, Russia, and China to gain traction in those emerging markets while simultaneously developing me-too drugs for their domestic markets. So, who’s in charge, the US Food and Drug Administration (FDA)? The European Medicines Agency (EMEA)? A player to be named later? The answer to the question seems to be “all of the above,” which adds to the complexity of the clinical trial process.
As digital technology has made data easier to collect and share, it would seem that clinical trials would be a great place to start intersecting with the quantified-self movement. The shift to electronic health records, the widening adoption of all sorts of health tracking devices, and the rise of (relatively) cheap genomic sequencing should signal an ability to identify conditions, and populations, eager to participate in clinical investigations. But so far, it hasn’t.
What might challenge that stasis? In November 2013, three major pharma companies – Novartis, Pfizer, and Eli Lilly – announced via the White House’s website that they had joined together in a clinical open innovation effort. That page on the White House’s site is gone now – changes in Presidential administrations will do that – but here’s a direct quote from that announcement:
“In order to connect patients and researchers, Novartis, Pfizer and Eli Lilly and Company, are partnering in the U.S. to provide a new platform to improve access to information about clinical trials. The platform will enhance clinicaltrials.gov and will provide more detailed and patient-friendly information about the trials, including a machine readable ‘target health profile’ to improve the ability of healthcare software to match individual health profiles to applicable clinical trials. As part of the project, patients can search for trials using their own Blue Button data.”
Five years later, and we’re still stuck on the slow train when it comes to really reinventing the clinical trial.
I’m one of a growing group of people who think that the entire life-sciences process chain needs to be re-tooled for the 21st century. In my view, the best place to start that re-tool is at ground level, with the patients and clinicians who deal with challenging medical conditions daily. If a doctor has a number of patients who might benefit from some clinical study, why isn’t there an easy way to find a researcher looking into that condition? If a patient has an idea for a clinical investigation into his or her illness or condition, why can’t they find a researcher who’s interested in the same condition to team up and start a science project?
I can only hope that the regulatory agencies involved in life science oversight (hello, FDA!) can move beyond the aftermath of Thalidomide – for which epic disaster we’re still paying a price when it comes to the timeline for drug approval in the US – and toward a process of “all deliberate speed” that doesn’t forsake speed for deliberation. Both are necessary, neither should be more heavily weighted than the other.
We all can, and should, take part in scientific exploration into human life, and human health. Got an idea for a clinical trial? Share that idea in the patient communities you hang out in, and ask your tribe to help you bring that trial to life. To quote Arthur Ashe, “Start where you are. Use what you have. Do what you can.”
We’ve got to start somewhere, right?
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.
Hearing your name and the word “cancer” in the same sentence is a world-shaking moment. After getting a cancer diagnosis, telling your family about it is another big step, one that can be fraught with as much emotion as hearing that diagnosis yourself.
Once the emotional dust has settled, talking with your family about treatment options, including clinical trials, can raise the emotional temperature again. If your family is like mine, everyone has an opinion, and is more than ready to share it. Even in families where everyone is calm about big issues like this – I question that those families exist, but I’ve heard they might – talking about clinical trials as a treatment option means being ready to field questions, and guide the conversation.
The American Cancer Society has a great set of resources for people who are assessing whether clinical trials are a good option for their treatment. I’ll use some of those as a framework for a discussion guide you can use to walk your family through your decision to explore clinical trials for your cancer:
- Why do I want to participate in a clinical trial?
- Your reasons can be anything from “I want to try cutting edge treatments” to “my cancer is advanced stage, and I want to throw everything but the kitchen sink at it.” The key here is to have an answer ready to this question when you discuss treatment options with your family.What are the risks?
- What are the risks?
- Here’s another question you’ll want to gather answers for, for yourself, before opening a conversation with your family about enrolling in a trial. Your oncology team can help you put together a risk profile for trials, and further help you target the right trials via molecular profiling of your cancer.
- Will my insurance cover the trial?
- Federal law requires that most insurers cover routine costs of cancer trials. However, like so much about US health insurance, the answer can still be “it depends.” There’s a great tip-sheet on the National Cancer Institute’s site that addresses this topic. You, and your family, and your oncology team, will be working together to make sure your costs are covered, either by your insurer or the trial sponsor.
- What happens if I’m harmed by the trial – what treatment will I be entitled to?
- Here’s another “it depends” situation. Addressing harm to trial participants is an ongoing ethics issue in the US. The key here is to review all trial enrollment documentation fully – with help from a medical ethicist or legal eagle who’s not involved with the trial, or your oncology team – and have any potential harm scenario fully spelled out, including who will address the remedy for harm, and how that remedy will be delivered.
Having solid family support is a key factor in managing cancer treatment, and in thriving as a cancer survivor. Getting your family involved in your care by talking through your options and decisions with them will give them a sense of involvement in your care, and its outcome. They can help you through the down days when side effects have you feeling punky, and celebrate the bright days with you when scans show progress against your cancer.
Curing cancer is a team sport. You, your family, and your oncologists are all on that team. Work together toward a win, which often includes unlocking the power of precision medicine via clinical trials – which can become a win for other cancer patients, too.
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.
Does the Clinical Trial Process Need an Extreme Makeover?
Many cancer patients feel that the clinical trial process is in need of a serious makeover. One of them is Jim Omel. Jim, a retired oncologist living with multiple myeloma, turned patient advocate, makes it his business to understand myeloma from the inside out. He joins this program to share his experience in clinical trials and how he learned about his vulnerabilities as a cancer patient.
Also joining the discussion is, Dr. Michael Thompson, medical director for the Early Phase Cancer Research Program at the Aurora Research Institute and an active clinical researcher developing new treatments, particularly early phase (Phase I and II) molecular biomarker-driven clinical trials.
Join us for a meeting of the minds on debunking myths around clinical trials. How are patients protected within a trial? Will I as a patient be lost in the clinical trial system? Can I select my own arm in a trial? The questions are endless and, left unanswered, contribute to the barriers to trial enrollment.
Welcome to this Patient Empowerment Network program. I’m Andrew Schorr from Patient Power. I’m joining you from near San Diego, Carlsbad, California, and I’m so excited about this program, Does the Clinical Trial Process Need an Extreme Makeover? Having been in a clinical trial, and I’ll talk about my experience in a little while. I am a big fan, but I know that people have concerns, and I know that the percentage of cancer patients who are in clinical trials among adults is very low. How does that affect drug development and having the chance to get closer to cures for us?
I want to thank the financial sponsors for this program who provided assistance to the Patient Empowerment Network. They are Celgene Corporation, Astellas and Novartis. They have no editorial control, so what happens in the next hour is what we say, the questions you ask, what we hear from our experts who are joining us.
If you have a question, send it in to firstname.lastname@example.org. Again, if you have a question, send it in to email@example.com, and our wonderful producer Tamara will take a look at it, forward it to me, and as we can over the next hour we’ll be discussing questions you have already sent in. And we’ll have a very inspiring, I think, and provocative dialogue between our experts.
So let’s meet them. I want to take you to Grand Island, Nebraska, where my dear friend Jim Omel is there. He’s a retired now family practice physician. And, Jim, for years you’ve been a myeloma patient. When were you diagnosed with myeloma, and what’s happened along the way? You’re taking regular treatment now, I think, some treatment for the bone complications. How are you doing, and when were you diagnosed?
Andrew, I was diagnosed in 1997. It started off with a plasma cytoma at T10. I broke my back, I underwent a stem cell transplant in 2000 and had six years of remission. It came back in 2006, and I had radiation and lenalidomide (Revlimid), and it went away a while. Came back again in 2010, and I had radiation, bortezomib (Velcade), Revlimid, dex, and it went into remission. And since then, Andrew, I’ve been so fortunate that all I’ve been taking is bone-protective bisphosphonates.
Oh, good for you. Now, you were in a trial, but you decided not to continue, but yet you’re a believer in trials.
Oh, absolutely. Without trials our treatment wouldn’t change. When I had a full evaluation at Arkansas they suggested that I join their trial, and I did, and at the end of that trial was a tandem transplant. And I got to thinking and reading, and I didn’t really want to get that extent of treatment. I had a single transplant, and I dropped out of the trial. And that’s one of the things that I would certainly tell our listeners, that they can stop a trial at any time. They’re not bound to it. Ever since then, Andrew, I’ve had the good fortune of having fairly responsive myeloma, and when I had my treatments they responded to standard therapy. I certainly would have rejoined another trial if necessary, but I was fortunate that it responded the way it did.
Okay. And before we meet our next guest, I just wanted you to list some of the committees you’re on, because you’re very active locally and nationally on behalf of patients. So what are some of those activities you’re doing?
Well, I’ve been doing this since about 2000, so that involves a lot of activity. Peer review with the NCI was one of my main ways to get started.
National Cancer Institute.
Yes, and I progressed on to the Board of Scientific Advisors, which was a really good, important work with the director of the NCI. I’ve been an FDA patient representative for many years and was on the advisory board that brought Kyprolis or carfilzomib to us. I spend a lot of time each month for sure with the Alliance Cooperative Group working with Paul Richardson as we bring you new trials to patients. I’ve been with CINBR, Center for National Bone Marrow Transplant research for several years, several advisory boards. I’m on two pharma accompany advisory boards as they seek patient input.
Wow. All right. Well, the point of this, what I wanted our viewers to get, is that Jim is—trained as a physician, worked many years as a family physician, became a patient, eventually had to retire. He’s been through a lot of treatment and is very much an advocate for all of us, particularly in this process of trials. So we’re going to talk about the unvarnished truth about trials and see how we can make it better. Okay.
Let’s skip over to Milwaukee, Wisconsin, where we’re joined by Dr. Mike Thomson, who is very involved in research, and Mike has been very involved in all sorts of programs related to education. So, Mike, first of all, welcome to the program, and tell us a little bit about your involvement both locally in research and in education of other physicians nationwide and worldwide.
Sure. So not as impressive as Jim, but he’s one of my heroes who has really dedicated himself to improving the clinical trials process. I have an MD, PhD. My PhD is in pharmacology, and I was interested in pharmacogenetics and how individuals vary in their response to drugs, especially cancer drugs. I did my fellowship at MD Anderson and worked with a lot of myeloma doctors there and have worked in the community setting seven years in one place and about five years now where I’m located at and Aurora Healthcare in Milwaukee. I have been on the NCI Myeloma Steering Committee. I’m currently on the NCI lymphoma steering committee. I helped organize the ASCO 2016 meeting. I was the Chair of Education. As of June, I’m one of the editors for cancer.net around myeloma, so taking over from Paul Richardson who did that. So I’ll have about three years doing that and probably asking people like Jim for help to provide educational materials for people. And in the world of myeloma, I’ve created the MMSM or Multiple Myeloma Social Media hashtag to have Twitter chats, which I know some people don’t think are the optimal form of communication, but it is a way to get information out from experts and some opportunity for patients to ask questions. So I’ve been highly involved in social media, highly involved in the NCI and NCORP for increasing access to clinical trials in the community. And right now I am in the middle of an NCI designated clinical trial called EAA172 for multiple myeloma, which has gone through ECOG Executive Committee, the NCI Myeloma Steering Committee, and now we’re discussing with the companies and with Ctap how to bring that forward. And I think that’s—one of the things is how much effort it takes to bring some of these trials from concept to activation.
Okay. Now, we’ve mentioned this more rare cancer, multiple myeloma, not rare if you have it, but Jim has it, Mike specializes in it a lot. But what we’re talking about applies to the clinical trial process about broadly. So we may have people with us living with lung cancer and hoping to live longer and better, prostate cancer, chronic lymphocytic leukemia, like me, are also myelofibrosis. I’m a two-fer, if you will. There may be many different cancers among our audience, and the process applies to all. So we’re going to talk about that. So whatever it is, ask your questions, firstname.lastname@example.org. I’m just going to share a little personal story for a second, because I’m very passionate about it, and I wanted to mention it. And this is part of our Clinical Trials MythBusters series, and we have previous programs on Patient Power with lung cancer experts, experts in other conditions about the clinical trial process, so look that up on patientpower.info. There will be a replay of today’s program and also a downloadable guide with highlights that you can share, talk about it with your doctor, with other patients, with people you know and for your review. Okay.
So now my own story. I was diagnosed with chronic lymphocytic leukemia, the most common adult leukemia, in 1996—terrified, had no idea what it was. Didn’t know anything about what a trial was, didn’t know what the treatments were. Quite frankly, thought I’d be dead like within a week. I didn’t know. And so you start getting educated, and eventually that led to me connecting with academic medicine specialists and ultimately suggestion at the appropriate time of being in a Phase II clinical trial. I didn’t know what the phases were, we may talk about that along the way, and it was 2,000 miles from my house. So I traveled a number of times to be in that trial, and I had my local oncologist collaborating on that. And the end result was I had a 17-year remission. I had treatment again for chronic lymphocytic leukemia. It wasn’t until last year, 17 years. And I got the combination of medicines 10 years before that combination was approved. So I’m a believer.
The second thing I’d say about trials was I was in a second trial along the way, and I had deep vein thrombosis, blockages in the veins in my legs, for a blood thinner trial. And by being observed in that trial, that led to them discovering a second cancer which was at work related to those clots, myelofibrosis, and I was observed, so I liked the attention. It had nothing to do with what they were testing. It had to do with the observation you get. So, again, I love the attention of being in a trial. It may give you access to tomorrow’s medicine today, but there are things that may be broken. So, Jim, let’s start with that. Jim, what has been some of the frustration points for you the way the process has been today?
Well, I think one of the main things, Andrew, is that clinical trials tend to be designed to answer scientific questions. I think what they should do is be patient friendly. I think they should be designed to help patients. If you ask any researcher, what is the purpose of the scientific trial, clinical trial, they will say, to answer a question. If you ask a patient, they’ll think the purpose of the trial is to help patients. The—it may seem like a minor point, but it’s not. Patients need to be the center of them. We need to help patients understand what their contribution is to a trial. For instance, hardly ever does a patient hear how their outcome, what they did during a trial improved the final outcome of a trial. The patient needs to be centered. If we get the trial to a point where some of the questions are pretty obviously answered, rather than continuing to recruit patients just to be statistically valid, I think trials should close sooner. I think they should be more focused on getting patient care without necessarily the scientific question. I’m not a radical. I’m certainly a fan of trials. We wouldn’t be where we’re at without trials, but I think they should just become more patient-centered and patient-friendly.
Okay. Now, Mike, Dr. Thomson, so we know we can’t have new drugs approved by the FDA unless there are trials, Phase I, Phase II for sure, and often, typically, Phase III and sometimes even monitoring after a drug has been approved. I think you call those Phase IV trials. But from where you sit having been around this a long time what are some of your frustrations? What would you like to see be improved?
I agree a lot with Jim. I think another word to put on it is pragmatic trials. So I’ve been on a number of advisory committees, NCI investigator-initiated studies and pharma-directed studies. And when you have an advisory group with a bunch of academics they often think about the theories, and they think about what would be interesting to know. And increasingly both the NCI and others are getting not only patients but community physicians who will say I don’t really care about this question here. And we don’t think that it will fly and won’t accrue, and we know a lot of trials don’t complete accrual, so therefore patients are wasted, if you will, because we won’t have the information, we won’t be able to answer questions. So I agree. There are so many things get to involved it’s hard to break them all down, but part of the issue is answering a clinically meaningful question. I think the meaning should be patient-centered. Within those questions you can ask scientific questions that are imbedded in what are sometimes called secondary imports or co-relative studies. But I just last week was talking to some pharmaceutical leaders, and I said, you have to design a trial to answer a question people care about, and that’s patients and physicians. Because sometimes the trials are designed to get FDA approval, and they’re comparator arm if it’s a randomized study, is an arm that we don’t think is the current standard of care, and we have to do them in countries where they don’t have as many therapies and they don’t have as much access, so they’ll get them done. But then when they’re approved in the U.S. we don’t know what to do with the trial, because it’s not a question we’re asking. So that’s important. And I think if more studies are done not to get FDA approval but to go on pathways and to ask, what are the clinical branch points for decision-making, I think that’s when you’ll start getting good trials.
There are a number of other issues around the pragmatics. So there’s this NCI Match study, tons of people screened, very few people on the matched drugs, and they switched over to a strategy more like an ASCO TAPUR, where they waited for people that already had testing and then the people that had already kind of pre-screened couldn’t get evaluated for the study. And many, many more people went on study. The imaging and other things in the middle were not as rigorous as a usual clinical trial. It rolled quickly, and I think the point is you’re looking for big end points. Where you have to sort of go back to the classical, randomized, Phase III large study is when you’re trying to make incremental improvements, so, for instance, breast cancer where the cure rate or progression-free survival rate may be in the 90-something percentile rate, or even CML or other things where we’re doing so well you’d need a lot of patients and probably a standard design. But in many other areas you can do a variety of different techniques—Bayesian analysis, continuous reassessment models.
And one thing Jim mentioned was stopping for futility or if there’s an obvious benefit, and that is done but probably not as often as it should be. And the designs using what are called interim analyses or futility analysis with data safety monitoring boards or DSMBs, probably could be more robust. There could be more of them. I think people are afraid to do them, because they do slow the trial down, they slow accrual, and that has to do with stuff both within the trial as well as extrinsic to it. So there are a number of barriers and issues, but I think Jim’s pinpointed them as well.
Okay. Well, folks, you can tell that Dr. Thomson is a scientist. We’re going to unpack this and get down to the nitty-gritty. So, okay. So, Jim, so first of all, we mentioned this term “randomization.” So people wonder in cancer am I going to get the good stuff? I know that I’m sick, maybe like in your area, multiple myeloma, there have been lots of new medicines, but in some other areas not, like pancreatic cancer, for example.
So, say, I understand the standard therapy, and you’re testing it maybe against that, but I want to get the good stuff, because I’m really hopeful. I want to be a believer. So could you just describe where we are with randomization, because that’s a concern people have?
Absolutely, Andrew, and thanks for asking that question. That’s a real red, red hot button item for me. I maintain that if the patient has gone through the effort of studying their cancer, studying the possible treatments, and they’ve learned of a trial that’s opened that they would qualify for, they’re excited, they go talk to the principal investigator, and they say I want to be in this trial. And the PI turns to them and they say, well, we’ll flip a coin. You may get the medicine we’re going to be using, or you may get standard therapy. Just imagine how disappointing that would be. And when it comes to randomization, Andrew, there’s many, there are many trials that absolutely lack equipoise. And I’m afraid that scientists often use equipoise.
Now, tell us what that means. You’ve got to define that for us.
Equipoise basically means equal, equal balance within the arms. In other words, technically, officially the principal investigator doesn’t know which arm is best. And yet look at it from the patient’s standpoint. Let me give you an example. There was a trial in which patients had the choice of three oral drugs in one arm versus a stem cell transplant in another arm. Now, think about that. Think of the insurance ramifications. Think of the fact that it takes almost a year to really totally recover from a stem cell transplant, versus taking three oral drugs. How can anyone say that there’s equipoise in a trial like that? So how can you pattern your life with the flip of the coin or a computer randomizing you into one of those arms?
Wow. That’s, that’s an important issue. Another one is, Mike, you know, people are—one of the ladies wrote in on Facebook I posted about this program, and she said, well, the trials are not really accessible to me because I live in a rural area, and they’re only in the big cities. You’re in one, Milwaukee. But Jim’s in Grand Island, Nebraska, and some people if you set requirements for the trial, well, you’ve got to come see me, you’ve got to come to the clinic for a variety of tests with some frequency and somebody has to drive four or five hours and take off work and get babysitters and all that, it just makes it impractical. Where are we with more trials being available or having an aspect of it, like testing, closer to home?
So I work at a community setting. I’m at our kind of flagship hospital but we cover most of the population centers of Wisconsin, so I think we cover about 70 or 80 percent of the population. So that’s a huge issue for our site is that we—when I talk to sponsors including as recently as last week I say if we can’t do it at all our sites I’m not really interested in doing your trial.
There are exceptions of course. We’re doing a surgical trial or a radiation trial that has to be at one site or sometimes a Phase I trial with just a lot of blood monitoring, very intensive, they can only be done at a few sites. But in general I completely agree that we should try to have the drugs available to people in the community they live in, because that’s where their social networks are, right? So that’s where their family is. They can stay at home. They don’t have to just go into a hotel. They don’t have to pay for travel, and I think it’s better for everyone. And for companies, I’ve been trying to tell them that it’s more generalizable to the reality of where cancer patients are. So
85 percent of cancer patients are in the community setting and are treated there, and drugs should be accessible to them there. So, you know, both the using the CCOP mechanism or NCCCP, and now we have the NCI Community and College Research Program or NCORP. The whole idea is to increase that access to community sites. So this has been going on a long time. I think there were budget cuts, and so the U.S. and the way we’ve established our cancer budgets has been to decrease access at least NCI trials and usually need some of those NCI trials to support the research infrastructure to do other studies. So I think part of that, you know, a lot of these things you follow the money. And if there was more money for community research sites, you could hire more research staff to get these things done.
But I think we need to get them done in the community, because we know if you do early phase studies and they look promising in highly selective patients, then when you expand them and put them in the community you go from efficacy to effectiveness, and the effectiveness isn’t there because the patients are different. So there are all these things with real-world data and comparative effectiveness research at ASCO’s cancer link trying to get at some of that not on study to just try to get the data.
But we need to have access to people, and the way to make drugs cheaper, make them develop faster and answer more questions, both scientific and patient-oriented, is to get more people on trial. There’s a big example for immunotherapy drugs where there are so many immunotherapy drugs and trials there are not enough patients to get it done. So we’re going to enrolling in trials which don’t complete, or we’re not going to be able to answer these questions, so it’s going to stall and move it out the process of moving faster. In myeloma, we move very fast, but we need to do this in other areas too.
Right. So let’s talk about that. So, Jim, you know, the president had a big kick-off, HHS Secretary Azar I think just yesterday as we do this program, was before Congress and part of it was the discussion of can we lower the cost of drugs ultimately? And one aspect of it is can we speed drug development. So instead of all these trials languishing at the cost of millions of dollars, hundreds of millions of dollars, how do we speed it up?
So one is participation, certainly, but can the process be simplified as well, Jim? What work is going on there, so we can try to get these answers and get to the FDA and present the data quicker, and hopefully there’s been lower cost in getting to that point?
Well, as we’re learning more and more about each individual patient, personalized medicine and targeted therapy, we certainly should start relying more on biomarkers. Biomarkers can be a way to select patients that would particularly fit a given treatment.
We need to lower costs. We need to make trials slicker and faster. Single-arm trials are those in which a patient just get—all the patients get the therapy. They all get the same treatment. And FDA has actually approved drugs based on single-arm trials, a much faster and efficient way to get an answer.
The problem is that the costs are going to be there. When I think about Mike and all the work that he does in developing his venetoclax (Venclexta) trial that he mentioned, Mike has put in months or years, and it’s all above and beyond his normal time. I mean his day job is to take care of patients, so all of the work that he does to develop a trial is just remarkable in the extra hours it takes and the consistency that Mike gives to doing his work. We need to make the trials more efficient.
We need to use biomarkers. We need to make them shorter. We need biostatisticians to come up with ways to give us an answer without having to approve so many hundreds or thousands of patients to all these potential new treatments.
So, Mike, let’s talk about that. And, Mike, first of all, I want to thank you for your—well, both of you, but, Mike, certainly in the clinic, thanks for your devotion to this.
But continuing on that, so this was brought up by Jim, biomarkers, and I know in some of the blood cancers now we’re talking about more and more minimal residual disease testing, and we’re doing genomic testing to see what genes have gone awry, what’s our version of lung cancer or a breast cancer or a myelofibrosis or whatever it is.
And then do we qualify for a trial? What’s our specific situation? Do you feel that that sort of precision medicine testing and analysis can help refine this, so we know which trial is right for which person at which time and also some analysis along the way of how is it going?
Yeah, so at my site I’m the director for precision medicine, and I gave a talk at ASCO on precision medicine and barriers in the community setting, so I’m very passionate about that. And I think that is one of the ways you can try to get things done with smaller numbers of patients and things done faster. And part of this is alignment, right? So there’s different perspectives, a patient perspective, a payer perspective, a pharma sponsor perspective, the physician. There’s all these different perspectives, and I think it’s trying to get them all aligned and trying to get things done faster.
So, you know, there are some areas where we don’t know enough, and we can’t use biomarkers. But there are other areas where we have a biomarker, and there’s feasibility, and we can test that quickly. And if we are looking for a large effect size—here I am in jargon mode—but if you’re looking for a big, big hit, a home run, is to look for an alteration that is very specific and we think is—a drug can target. So-called targeted therapy—it’s a little bit of a misnomer.
So—and lung cancer has been one of the hottest places for this. So there’s ALK inhibitors, ROS1 inhibitors, EGFR inhibitors, and now BRAF inhibitors, HER2 targets. So lung cancer has exploded with precision medicine therapy, and the same with melanoma and BRAF. So, you know, I think even skeptics will say you don’t really need statistics if the prior therapies, nothing worked, and you give something, and 80 percent of people respond.
There are issues with precision medicines, but the main thing is not response rate but durability. And I think that’s going to be the next iteration of the NCI Match study, which is a large precision medicine study, is stop doing just these small groups of people who are showing activity, but then they relapse quickly. And I think it’s going to look at systems analysis, and how do we overcome resistance.
But one way to get at this and another different take on it is inclusion and exclusion criteria. So this has to do with access and individualizing and being patient-centric. Many of the inclusion and exclusion criteria, when somebody says, oh, I have lung cancer, oh, here’s a lung cancer trial, and they say, oh, you can’t go on the trial. And much of that is because there’s language that’s been cut and pasted from a previous trial which is not really pertinent.
So if the new drug is metabolized by the kidney, you don’t necessarily need to look at the liver studies. And we did a small study or I was aware of a small study done by Kaiser where if we improve the inclusion-exclusion criteria, accrual rate can go up 30 percent—so no cost to that.
And Ed Kim led a publication about six journal articles in JCO about different aspects of inclusion-exclusion criteria including function, HIV status, age, etc.
Well, yeah. We had Ed Kim on the program just a week ago, as a matter of fact.
So, Jim, inclusion, exclusion, so first of all, we’re in this age where electronic medical records, it would seem that at your fingertips there could be some analysis of your record and some matching or offering of trials that could come out of an analysis of your results, genomic results. Do you have ALK or ROS or whatever, if it’s lung cancer, whatever it may be maybe JAK2 positive in myelofibrosis, what is various status for us?
And also broader inclusion criteria, and Mike was getting at that, saying some was just—excluding was just cut and pasted. And a lot of us patients would feel, well, that’s just unfair. So what’s your comment on all that, about inclusion and exclusion and analysis so we can be matched with trials more easily, can be offered to us?
Inclusion and exclusion criteria are really important parts of trials. They’re what get people into trials, they’re what keep people from being in trials. And, unfortunately, Andrew, many times the criteria are very defined, very narrowed, and drug companies especially want to do it this way to get the best effective appearance of their drug. They want to get approval. And yet in the real world, in fact most times, patients who would not even need inclusion criteria are the very patients that are going to be taking these drugs.
And Mike’s right. There’s too much cut and paste. If a trial takes a thousand patients to write a proposal or protocol, too many times researchers will just take the exclusion criteria that might have been from a previous trial and, like Mike said, cut and paste it when perhaps it’s not even necessary to have creatinine values or kidney values measured so precisely on this particular drug compared to the other one.
So those are the criteria that let people in or keep people out of trials, and they absolutely need to be widened. To make a drug more applicable to the general population we need to reflect the general population more in trials.
Right. Right. It’s sort of a Catch-22. So if somebody is at a drug company and they’re investing hundreds of millions of dollars maybe to develop a drug, and then that trial is languishing or taking longer to get there, somebody ought to go back and say, well, can I loosen up this criteria, get the big answer and do benefit to patients who may be very willing to be into a trial that doesn’t have all of these requirements that are not really necessary? And we get the answer and get it quicker, and help people along the way. I mean, it’s pretty obvious to me, and I hope they’re watching, folks.
So, Mike, here’s a question for you, though, and you work with people in the community setting. So we have patients who have written in and said, you know what, where I go to the cancer clinic they never mentioned trials to me, and Jim alluded to the extra time it may take for physicians and their teams is when there are trials. You have just treating people with current therapies, and then you’ve got research layered on top of that. It’s very time consuming.
But what about just awareness at the community level? What can we do about that so that wherever I go into a clinic they have a clear picture of what I’m dealing with, and if there is important research going on that relates to me I hear about it? Now, maybe they say, you’ve got to go to a university center, you’ve got to go to Milwaukee, wherever you have to go, but there’s that discussion.
Yeah, so with all of these, you know this has been analyzed in multiple different papers. We were on one looking at a trial log, trying to look at some of these issues, and what seems to be clear is when people are offered trials they tend to go on them at about the same rate, and that has to do—seems to be somewhat independent of socioeconomic status, race, etc., or geographic area.
So one of my colleagues, Dr. Verani, told us about—about this, about rural settings how do you get people on trial. So there are different barriers. So one is the trial, and like Jim said, if you can only do some therapy that you have to come in quite a bit for that limits the geographic area you can accrue to for most people.
There are site issues where if you don’t have enough research staff to be there enough the doctor doesn’t feel supported to spend time on it. There are physician issues where they may not care about trials, or they have too much people scheduled in clinic, they’re an hour behind, and they can’t stop to spend time on it.
Also in the community setting you may be seeing every type of cancer, and you can’t remember everything, versus at many academic settings you may only see one or a cluster of types of cancer. So if you’re seeing lung cancer all day and you have 10 trials open, you probably know those trials very well for lung cancer, because you don’t care about the CLL or myeloma trials, you only care about lung.
And then there are patient factors. So patients that are in rural Wisconsin may have different characteristics, and the reason they’re in rural areas, you know, the motivations is about, you know, going in for things and stuff like that may be different than people who have the capabilities to fly to Boston or Houston or New York, and they can do that. So all of those areas are important.
Now, one potential way to help mitigate some of those things is we have got a clinical decisions support tool, which is an IT product, which our physicians have to enter in what they’re going to do with the patient. So it could be observe, no treatment, hospice or various therapies. And when they put in the cancer and the stage it pops up with the clinical trials, the first thing that pops up. And so the physician doesn’t have to do the trial, but they have to say why they’re not doing it. And so we can track over time. It doesn’t necessarily help that individual patient, but that doctor has been aware of the trial, and we kind of get an idea of why people are not going on studies, and so that’s one way to do it.
Something we just did the last week is we had a different IT product where the NCI-matched precision study opened up five new arms with different targets for different drugs. So we looked back at the number of patients that had those targets identified within our entire system, and then we screened those to see how many people were still alive, and were their organ functions still good enough to go on these trials because of the inclusion-exclusion criteria, and we found several. So we’re now able to contact the physicians and the research staff to go back for these patients that had screened for molecular testing and now they have new options.
So I think there are IT issues that you can do systemically to try to take some of those barriers away, and then each of those points does have barriers which probably have different solutions and different ways of tackling. But one reason, you know, the accrual rate hasn’t gone up a lot is it’s not easy. It’s a complex problem, so there’s not going to be one single thing you do. There’s going to be many different ways to try to improve things, including patient education.
Yes, well, okay. To let’s flip that over. Jim, you and I are patients. So what do we want to say, and from your perspective?
So back at the clinic and from group has, so Mike is working on IT to identify trials and have it pop up on the screen for the doctor. Okay. Great. But we’re the ones living with the condition. What can we do so that promising research that we may learn about is available to us? We can see whether it matches up with us. Maybe we have to go down the road. Maybe we have to have a discussion with our doctor to even encourage them to have you us be in a trial. How do we make it happen, okay?
Well, of course, we all need to educate ourselves about our cancer. When I was in medicine school I had heard about myeloma, but I certainly wasn’t any expert in it. I had two patients in my practice that had myeloma. I knew sort of how to take care of them. But since I developed my myeloma, I have become my own expert. And as I lead my support group, Andrew, I make them experts. I teach this cancer to them so that they can make educated decisions.
Patients are very likely to go on the Internet, watching Patient Power. In my particular cancer, they’re going to go to the IMF and MMRF to look at myeloma trials and see what’s available. And they will take that information to their doctors, many times making their doctor aware of trials that perhaps they aren’t each advocating or aware of.
So, Mike’s right. There are many factors that keep patients from trials, but one of the things that patients really do themselves is educate themselves and perhaps even to the extent of bringing or educating their doctor about what can be available for their treatment.
Mike, I want to ask you about cost. So you mentioned different inclusion, exclusion, or what’s your liver function or this or that. So there is a problem where maybe certain drugs or certain aspects of a trial are covered, but then your insurance company, you know, that you have or Medicare or whatever, they say, oh, no, we don’t pay for that, but yet it’s part of the trial or it goes along.
So people have a concern about cost. I want to ask you about two aspects of cost related to testing sometimes. And then also are there programs that can assist with the logistical costs for patients as well?
So when I trained at Mayo Clinic and MD Anderson, and when I got—first went into practice I prided myself in not caring about cost. And then I realized you have to think about these things because you can bank—you know, we bankrupt, about 40 percent of people with cancer get bankrupted. So these are huge issues for people who want to keep their houses, that want to hand something down to their kids, and cost is huge, right? So that can either be throughout the whole course of standard treatment, or it can be trying to meet the cost of going places, trying to find clinical trials.
So the Affordable Care Act and various other national and state legislative initiatives have tried to make insurance companies pay for the standard costs in clinical trials. There are some carve-outs for smaller companies and things like that, and so this is, you know, not perfect, but in general insurance companies should pay for the standard cost of clinical trials. They should pay for standard imaging stuff too, and they try to get out of that. So it’s not a perfect world, but that should be covered. And any research-associated costs should be covered by the company. Even in some NCI trials some people disagree with what should be covered and isn’t, and it’s complicated. But in general, a patient, the research cost should be covered.
Now, that does not include travel, lodging and a lot of incidentals. So there are a variety of foundations, that could be The Leukemia & Lymphoma Society, that could be other organizations which could help with that. Individual hospitals or health systems might have ways of approaching that. And sometimes there are things you can do within the various companies. So there’s a new target called Entrek, and the company Loxo, I’ve heard will fly people who wherever there’s a site and pay for them to go on the study, which I think is amazing. That’s not true for every company and every drug being developed. But that’s one way to do it.
One of the issues that comes up with IRBs if you’re giving people money, are you coercing them? And, you know, if you’re just recovering the cost to travel, I don’t think you are, right? But those are one of the things that come up. But certainly there are lots of disparities. And just like in different countries, they don’t have access to the drugs we have as standard drugs here, and not all of these disparities are going to be fixed because we have—outside of cancer we have lots of disparities in the United States, but cost is a big issue.
And then value, which we’ve been increasingly talking about in the oncology community, which is utility over cost. And that’s more for once we’ve done the trial figuring out even if shows like it works, how do we figure out how to use it based on those characteristics?
Thanks. And also I wanted to mention that Mike Snyder is sending that question, answering why it cost so much. I hope that answers it.
We have—you know, some people wrote in as we were preparing for this program and they were bitter because they thought they had a spouse, let’s say, that had died in a clinical trial. And that relates to a couple of things. One is transparency. Is the data from a trial and any dangers that show up, is that reported and analyzed in public, Jim? And also what are the risks being in a trial, and what is the monitoring to try to have trials be at safe as possible. So, Jim, maybe you could talk about that from a patient perspective.
I want to make sure I know what I’m getting, I know what the risks are, and if any have come up along the way I want it to be reported, and I want to know that there’s a team looking out for me.
You have every right to expect that, Andrew. If you’re in a trial you have the right to get that knowledge if there’s new things that come up that we’ve learned about. And part of every trial as it’s being written, there has to be a data safety monitoring board. These are the experts who will do what you’ve asked be done. They will monitor the trial as it goes along. They will look for any safety issues. If there are patients who are developing liver toxicities, they will find this. They will point this out and perhaps see if the trial needs to continue or if something needs to be revised.
The presence of institutional review boards review whether trials should go forward or not. Patients who are in trials actually get very, very good medical care and medical coverage. In fact, I would maintain, Andrew, that they get better care than just standard care. They have experts that are watching them even more carefully than would be in a general routine care setting because they’re looking for these concerns and problems.
The person who mentioned the bad outcome, we can’t ever say that every trial is going to be perfect. There are going to be concerns. That’s why trials are done. But they’re relatively rare, and we do have boards and review organizations during the trial, not afterwards, but during the trial to be looking out for your benefit, Andrew, so that you’re not hurt by the trial.
All right. But let’s say this—and, Mike, for you. So, first of all, admittedly a lot of these trial start, and people are sick people, and they’re feeling maybe the trial is their last hope. We had a friend, Lisa Minkove, who died in the CAR-T trial for CLL not long ago. She had been very sick with CLL, so we’d hoped that it would work. It didn’t work for her, whether CLL won. And we know other people whereas the learning is going on about often powerful new medicines they didn’t benefit. Or in one case, there was a drug, venetoclax we know about, there were some deaths early on when the drug was far more powerful than was originally understood. So what do we do? I mean that’s the real world I guess of scientific study, but that’s a concern, you know, Mike, of people saying, oh, my God, I’m worried about being a guinea pig the unknowns on the subject of dangers.
So there are a couple of things. So whenever people say—it doesn’t come up as much recently about being a guinea pig, I say, well, guinea pigs don’t have choices, so. And so like Jim has said you can drop off a trial if you want to drop off it. But—so I think for adverse events and things that can happen, one reason to randomize people is that you do understand then if you treat someone with one thing and then another and the death rate the same in both, the drug is not causing it. That’s just the disease. And a couple years ago, there was a presentation from the group at Dana-Farber on the precision medicine program, and the issue was they were taking so long to get people evaluated that their performance status or how well they felt was good, and by the time they got through the evaluation many of them had died. Because the disease, you know, when you get to fifth, sixth, seventh-line therapy it can often progress very rapidly.
And so I think that’s one of the issues, that people can feel the drug did it, and it’s hard to know. And we get these—doctors get these things called adverse events reporting forms, and we have to try to come up with is this probably related, possibly related, and we also get these forms that say you have a patient on the study. The study is open in three countries, thousands of people on it. One person died of a heart attack, and you have no idea as the physician, well, is that the same rate as—you know they’re 70 years old. Is that the same rate as this other 70-year-old. So you need the enumerator and the denominator, and that’s what the DSMB or the Data Safety Monitoring Board is supposed to do, which is look at the data and say, is this beyond what we would expect? And they can stop the trial. They can do expanded cohorts. They can do things to try and figure that out. Now, we know from like even car companies lying about their exhaust systems that if the Data Safety Monitoring Board gets false data, well, you can’t fix that. But that’s pretty nefarious. Like that I think is not something that’s commonly happening and would be a very serious thing to happen.
Now, one thing for transparency is that almost all studies I’m aware of get registered on clinicaltrials.gov or maybe some other sites but usually that site, and they’re supposed to report out the outcomes. It’s not also a perfect process, but you should be able to see how long the study has been open, are there any complications related to it and those types of things. So this whole process is not perfect, but I would say in general the people at the companies are trying to develop something they think is going to work. They’re trying to do it safely, both to help develop their drug well as well as to avoid a bunch of regulatory issues, and the people on the Data Safety Monitoring Board are trying to do their best to answer these questions. But the smaller the number of patients which increasingly will take the trials we are doing and almost are aiming for, it’s harder to be definitive about when these things happen and what caused it.
Right. Right. It’s imperfect, as we said. So, Jim, Mike Thompson mentioned earlier, gave lung cancer as an example and, of course, across immunotherapy, there are so many companies endeavoring to move this research along. So let’s say you had lung cancer or one of these others where this is big, although it’s going on in the hematology area too, so a patient says, oh, my god, there are all these trials, and I might qualify for one, two, three, four. How do I prioritize? What do I bet on? And maybe my own doctor is doing more than one. So what do you say to patients if they become receptive to being in a trial and there’s more than one trial that they qualify for?
That’s a very good question, and it’s a nice kind of problem to have, to have choices of trials. I think, Andrew, the best answer is the patient needs to look at what they are looking for. Are they looking for longevity? Are they looking for something that’s going to expend their life? Are they looking for a trial that maybe will greatly improve their quality of life? Perhaps they’re looking for a trial that gives them one pill per week versus two injections a week. So there are certainly effectiveness end points. There are different things that patients find of value.
But to answer your question it really comes down to each patient needs to ask themselves, what is it I’m looking for in a trial? Do I want something that makes my burden lighter? Do I want something that’s going to extend my life? How much am I willing it accept as far as potential problems versus the standard of care that I know what the problems exist with if I don’t go on a trial?
Right. So that’s a question we got in, is they’re trying to assess that. One was about how do I prioritize? The other is, by being in a trial, Mike, is it going to make me sicker? Like, to do I have to go through the valley of the shadow of death to get, hopefully, to a better place, and how do you discuss that with your doctor when not everything is known?
Yeah, maybe I’ll kind of step back and say for phases of trials, Phase I, the intent—both ASCO and NCI say the intent of a Phase I trial is therapeutic. But the statistical design is to evaluate safety. A Phase II is to look at initial efficacy or how well it works, and Phase III is to compare versus standard of care the efficacy. So there’s other types of designs, phase 0, Phase IV and other things, but it used to be, I think, you know, I—we would say don’t go on a Phase I unless that’s the last option because you’ve already gone through the safety initial efficacy if it’s a Phase III trial. It costs a lot of money to do Phase III trials so fewer are being done now, and we’re kind of finding that in this era of precision medicine people are going on trials, and there’s no one rule, but I look at it as if it’s a study involving a lot of different groups of patients, a lot of—you know, it’s not individualized to you, I don’t know, but I think it will have less of a benefit probably than if it’s something like a study designed for BRAF melanoma back when that was a study and you have BRAF. Well, it’s targeted for you. It doesn’t mean it will work, but even if it’s an early phase, a Phase I or II trial, it’s really aimed at your disease.
And we’re finding this with venetoclax, with T1114, and there’s other markers, FLT3 in AML, all these things, and sometimes we find that the drug doesn’t work like we think it’s going to work. The ALK and ROS story in lung cancer, it may benefit other people that we didn’t recognize before, and that’s part of–we’re trying to find people besides T1114 that respond to venetoclax in myeloma because it looks like some people will. But I think as we’re getting more targeted therapy it doesn’t mean there’s no toxicity, but it at least has the suggestion that we’re targeted more at your specific cancer. And some of these pills can have as much toxicity as IV chemo s, but our aim is to decrease toxicity and increase efficacy. And I think, like Jim said, you’ve got to look at different trials and hopefully with a physician who has time to sit down and run through several scenarios. And some people will take the most aggressive therapy because that’s what they’re after, and some people will try something that’s easier and closer to home. So everyone’s values are a little bit different, and you have to try to individualize as a patients.
One thing about trial matching is besides clinicaltrials.gov, there’s myeloma and other groups that are doing these matching, so you can put in characteristics of your cancer and you can try to filter out and get a closer approximation, including at clinicaltrials.gov you can click on the states in the surrounding area or how many miles you’re willing to travel.
Right. I would mention, put in a plug for our advocacy group friends, whether it’s Lung Cancer Alliance, Bonnie Addaria Lung Cancer or the International Myeloma Foundation with The Leukemia & Lymphoma Society, you can be in contact with them directly and talk about your situation, and they will often be very aware of trials and how it’s starting to line up with these sub groups, subtypes of illness. Here’s a question we got it in with Jack. I just want to get in a couple more before we have to go. This relates to what you were talking about the National Cancer Institute’s Match trial, as I understand it, Mike. He said, regarding precision medicine I thought I heard that initial results have been disappointing for the NCI trial which treats patients with a specific mutation with a specific drug for that mutation. How does this impact precision medicine? You want to talk on that? Mike?
Yeah, so the people who are opponents of precision medicine would say that the SHIVA trial in Europe and the NCI Match trials were failures. I think you need to look at it a little more carefully. And if you do a huge screening and you don’t have many drugs you don’t have many matches and not many people are going to benefit. So there are some arms in match that match the accrued the number they wanted, and the drugs didn’t work well. So those were truly we think negative studies. But I think the things about Match are there is a huge interest in the community, and they had thousands or several hundred people screened when they only had a few arms opened, and those people weren’t matches, and it basically overwhelmed the system. And then they had to rejigger it to open up more arms. So I think we could—you know, pick holes in the design of the initial study, but I think it took everyone by surprise how much interest there was in trying to personalize these molecular therapies. And other iterations such as ASCO TAPUR, there’s company versions of it like Novartis Signature, and I think the new design of Match do allow for better match rates, and we’ll see how after they’ve adjusted how well they can hit their targets.
Okay. So that’s an example, where we’re going through a makeover there. Before we go, Jim, we have people watching from all over the world, and Mike alluded to sometimes trials done in other countries. Certainly they are. So we have somebody from New Zealand, we have people from other countries now. How do I access trials? Does it have to be in my country? Or what would you say to an international audience as far as finding out what’s available to them?
That’s a difficult question because every country has their own standards. Each country has their own boards that review. What is allowed in some countries are not even allowed. Observational trials can have more importance in some countries than others. Again, it’s a tough question. I think perhaps the person who asked it really needs to be again their own advocate and go online, go with their physician, go to their local support groups, go to their national groups, because they’re the ones that can give that local person their answer. There’s no one set answer for every country because there are some many variances.
Right. I do want to tell one of my favorite stories. I had a friend Jan Rin in Dublin, Ireland. She had a tremendous problem with more advanced chronic lymphocytic leukemia, one of the conditions I have, no trial for her there. She heard about Imbruvica being studied in Leeds, England, different health system, national health system. She was in Ireland, didn’t have it. She got permission from the Irish government to go over to Leeds and be in Dr. Hellmann’s trial there, and I think it saved her life. She would tell you that. So she had to be pushy. There were newspaper articles. She had to do lots of things to make it happen. It’s going to be varied by country but it starts with…
…drug like the one you mention, and it’s not available in the country, and there’s so much of that in myeloma. We have many, many drugs in the US that they don’t have in other parts of the world, and it would be so sad to be a patient in those countries, know that a treatment like that is available but not have access to it. So we all need to work to get these drugs available to patients wherever they’re at.
Right. Amen. I want to just get some final comments from you. We may just go a couple minutes over. So, Mike, the process is improving, I hope, you’re working on it. Can we feel confident that these gaps, if you will, improving it for prevision medicine, more awareness among the doctors wherever we may go, financial assistance, working with the insurance companies, are you working on it so that this process, we can have some improvement and hopefully have higher levels of enrollment and can get drugs approved quicker?
Yeah, I think we’re all very concerned about it. We should all be aligned in having more patients on trial, moving things faster and getting it done more cheaply. And I think we’re making progress. It’s not as fast as any of us want, but we’re all trying to move the ball forward.
Okay. So, Mike, it comes—excuse me. Jim, it comes down to us then as patients. We have to push, right? We have to see what’s within ourselves, what are we willing to do, understand our clinical situation and what’s going on for our cancer, and we’ve got to push, right?
And one of the things we need to push for are more interesting trials. We need to make pharma companies put up their drug against another pharma company’s drug. I think it’s so troubling when they’re afraid to take big steps. They just take little, incremental steps with their trials. If we can put drug A of one company versus drug A of another company—pharma companies are really reluctant to do those kinds went trials, and yet those are the kind that would be exciting to patients. I could give certain names of myeloma drugs, but we won’t get into that. It just needs—we need to get better, more interesting trials, and that will attract patients.
Okay. So I want to just put in a plug for something. We started something at Patient Power called the Patient Power Ambassador Program, and you can see it listed on our site, where you can share your voice. So we can all work with Jim, work with Dr. Thompson, and we cannot just be getting what’s right for us, but we can push on this process. So please consider doing that. Because I want to thank you, Jim Omel, for not just getting what’s right for you as a myeloma patient, but working on these government panels and with advocacy groups to try to advance it for all of us. Jim Omel, thank you for doing this.
Thank you, Andrew. It’s a pleasure to do this, and I’ll keep doing it.
Yes. And long life, Jim. Thank you.
And, Dr. Mike Thompson, thank you, Mike, for your leadership too and those extra hours put in, not just for programs like this but all the clinical research speaking to industry and the government to try to improve this process. Thanks for being with us, Dr. Mike Thompson.
Thanks for having me on, and I think this is the some of the most powerful patient educational material that people can get, this type of program.
All right. Thank you so much. So, folks, we’re all in this together. So you have your own issues about whether you know about trials, whether you want to be in a trial, that’s right for you or a loved one, whether it’s close to home, not close to home, so—but we have these discussions. So please look ongoing at the clinical trials mythbuster series. The let us know how we did today. You can always write to me, andrew@patientpower. Our producer, Tamara, T-A-M-A-R-A, at patientpower.info. And talk to your own doctor and your own healthcare team about clinical trials and where they line up, what are the obstacles, for you participating. And let’s see if we can improve this process and ultimately have more medicine that can lead to a cure for us be available sooner. Thank you for watching. We’ve done our best today, but this is an ongoing discussion. In Carlsbad, California, I’m Andrew Schorr. Jim joined us from Nebraska, Dr. Mike Thompson joined us from Wisconsin. Worldwide, we’re here for you. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
Please remember the opinions expressed on Patient Empowerment Network are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
You’ve gotten a cancer diagnosis. You’ve selected an oncologist as your partner, working toward “No Evidence of Disease,” or NED (NED is every cancer patient’s very best friend). Your and your oncologist are working up a treatment plan, and you want to talk about clinical trials as part of that plan. Should you kick off that discussion, or wait until your onc brings it up?
YES, definitely bring up clinical trials yourself, if your oncologist hasn’t started that conversation. If you’re not sure how to kick off that discussion, here are some tips.
- “Just do it.” Lace up your mental Nikes, and just ask the question. Have some resource links handy at your next oncology team visit, or start the conversation before the visit via your onc’s patient portal. Start with the information on the Patient Empowerment Network’s Health Centers and Programs hub, take a dive into gov, or check out the American Society of Clinical Oncology’s Cancer.Net trials site.
- There’s an article in the Journal of Oncology Practice, “Identifying and Selecting a Clinical Trial for Your Practice,” that talks clinicians through the process of selecting clinical trials for their oncology practice. Reading through that can help you craft some great questions, and open a productive conversation with your treatment team about clinical trials for your cancer.
- The National Institutes of Health has a great tip-sheet for oncologists on how to talk to their patients about clinical trials. You can use that to frame the conversation you’d like to have with your own oncologist about your clinical trial options. I’ve often found that reading articles and tip-sheets aimed at the clinical side of the equation have helped me accelerate discussions with my own clinical teams about treatment options, for cancer and for other medical conditions.
When you’re dealing with a cancer diagnosis, you want to have all your options on the table, and make the most informed decisions possible. Opening up a dialogue with your oncology team about clinical trials early in the treatment process will give you the information you need for those “most informed decisions.”
Another reason to open those discussions early is to gauge your oncologist’s response to shared decision making, and participatory medicine. If your oncologist doesn’t welcome self-advocacy on your part, it’s better to know early in the treatment process so you can shift to another, more participatory practice.
You are the focus of your cancer treatment team’s work. Lead the discussions, share your perspective, and participate fully in your treatment planning. Opening the discussing of clinical trials is a great way to get your team on your page about treatment and outcome preferences, and to unlock the power of precision medicine.
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.
“Be skeptical. But when you get proof, accept proof.” – Michael Specter
That quote is from Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens Our Lives, where New Yorker staff writer Michael Specter examined the distrust of science that’s turned discussion of scientific topics into a potential minefield. Some good examples of that minefield are climate change, and childhood vaccinations.
Anyone interested in scientific progress – full disclosure, I’m in that group – needs to understand the ideas being explored in scientific papers, the dispatches from the front lines of scientific thinking and discovery. To arrive at that understanding, you have to be able to understand what you’re reading, and I’ll be the first to admit that isn’t easy.
Scientific papers are written by scientists, for scientists, and follow a set of rules and formal structures that can feel like they’re designed to prevent any understanding by the average Joe/Jane “just plain human.” In this post, my goal is to help anyone interested in, but not formally trained in, science tackle reading – and understanding! – an article in any scientific journal.
10 steps to scientific (article) understanding
Check the source
- What journal is publishing the article? Check Beall’s List, and if the journal appears there, you can stop reading – it’s a fake journal.
- Who is the lead author, and what organization or institution is s/he affiliated with? If it’s an established university or research institute (University of Chicago or Scripps Institute, for example), keep reading.
Read the introduction first, not the abstract
- The introduction will reveal the Big Question, the one that the research project worked to reveal the answer to. For instance, an article in the Christmas 2017 issue of The BMJ reports on research into the effects of pet ownership on human biomarkers of ageing; the introduction clearly lays out the Big Question as “ we examined the prospective link between pet ownership and a selected range of objective biomarkers of ageing proposed for use in large scale population based studies of older people.”
Write out your own summary of what the research was examining
- This will give you a grasp of why the researchers wanted to ask the Big Question, and a framework for assessing what their answers to that question are.
Identify the null hypothesis
- The null hypothesis could really be better termed the “nullifiable” hypothesis, since the purpose of the research project is to nullify the hypothesis that there are no differences in possible answers to the Big Question.
- An example of a null hypothesis is “the world is flat,” which is what Copernicus worked to scientifically disprove a while back. He was successful, but there are some people who still reject his conclusions. (Warning: opening that link might be hazardous to your sanity.)
Look at the approach, and the methods, used in the research study or experiment(s)
- What did the researchers do to answer the Big Question? What specific experiments did they run?
- Sketch out diagrams of each experiment or data crunch.
Read the results section of the article
- Look at the written results, as well as all charts and figures related to those results.
- What are the sample sizes? Really small sample sizes are a red flag.
- What results are listed as “significant,” and what as “non-significant”? If you want to totally geek out on this topic, this post will make your geeky day.
Do the results actually answer the Big Question?
- Using your own judgment, do you think the study authors have answered the question asked in the introduction?
- Do this before you read the paper’s conclusion.
Does the conclusion make sense, in light of everything you’ve read and evaluated while going through the paper?
- Do you agree with the conclusion?
- Can you identify an alternative explanation for the results in the article?
- What are the next steps the authors see emerging from their research?
Read the abstract at the beginning of the paper
- In light of the work you did in Steps 1 through 8, does the abstract line up with what the authors said their research purpose was?
- Does it fit with your own interpretation of the paper?
What are other scientists saying about the paper?
- Have other scientists written about this paper?
- What other research is referenced in the paper?
- Have the authors of that research weighed in on the paper you’re evaluating?
Reading, and understanding, scientific papers takes practice. It’s also fun, if you’re a science nerd, or just interested in new scientific discoveries. And it’s work worth doing, because the more you know, the more likely it is that you yourself might make a discovery that makes a difference.
What YOU Can Do to Advance MPN Research
An audience of MPN patients and their caregivers joined us online or on the phone as experts discussed what patients can do to advance research and to raise awareness for MPNs.
It is Blood Cancer Awareness Month so our webinar is what YOU can do to advance MPN research. I’m Beth Probert. I am a polycythemia vera patient and advocate.
I was diagnosed with PV in April, 2016 and I had about 12 months of treatment which included a few phlebotomies and interferon, Pegasys. I reacted very well to Pegasys and I am now in remission. I get my care at the University of Southern California Norris Cancer Research Center in Los Angeles. I’m coming to you live from Oxnard, California, which is just north of Los Angeles on the central coast.
I would like to start off by thanking our Patient Empowerment Network for their support, and the MPN Research Foundation for their continued partnership.
I’d like to welcome our guests today. We’ll start off with Dr. Verstovsek, who is a renowned MPN expert from The University of Texas MD Anderson Cancer Center. Thank you for joining us today, Doctor.
It’s my pleasure. Thank you very much for having me on the program.
And I’d also like to introduce you to Lindsey Whyte, from the MPN Research Foundation. Lindsey, thank you for taking the time to join us today.
Thank you so much for having me. I look forward to enjoying this esteemed panel.
Thank you. We have two patient panelists today joining us. Both have been in clinical trials and both run support groups in their area. Our first patient panelist is Nick, and he’s coming to us from central Florida. Thanks for joining us, Nick.
Thank you very much, Beth. Appreciate it, glad to be here.
Great. And I’d love to introduce Andrea, our other patient panelist. And she’s coming to us today from Dallas, Texas. Thanks for joining us, Andrea.
Hi everybody, it’s great to be here. Thank you.
Great. I’d like to start off our program today just getting to know a little bit more about Nick and Andrea. Nick, I’m going to start off with you. You were diagnosed with myelofibrosis in February, 2016. Let’s talk about when you were first diagnosed. What was your first move after diagnosis?
Definitely I was quite shocked. I was asymptomatic, and the doctor who presented me with the diagnosis really didn’t give me a whole lot of information; basically a Google printout that said I had one to three years to live. So, I traveled throughout the country, hooked up fortunately with Patient Power and MPN advocacy; went to a seminar in Stanford, outside of San Francisco with a wonderful group of doctors there to really learn about the disease.
Ultimately went to May Clinic, Dr. Tefari; Hutchinson Clinic, Dr. Mesa in Scottsdale, Arizona; and finally spent time with Dr. Pemmaraju who works with Dr. V. at MD Anderson. I felt it was important to try to learn as much as we can about the disease to try to help other people behind us, so I signed up for a trial with azacitidine and Jakafi at the MD Anderson hospital, which was phenomenal. They did a wonderful job but unfortunately my blasts had spiked up and I had to go to transplant, which I did a transplant on January 15 of this year.
Wow, you have really been through quite a lot in such a short period of time. We’re definitely going to come back to you and talk about some of those details you gave us more specifically. Thank you.
Andrea, I’d like to go to you, now. You were initially diagnosed with essential thrombocythemia about 19 years ago, and then you were later diagnosed with myelofibrosis about nine years ago. So, you’ve certainly had quite the journey. I’d like to hear a little bit about how you reacted when you were first diagnosed.
Sure. My primary care doctor was really great in seeing that my platelets were rising. And while they weren’t that high, she still sent me to a hematologist just in case; a local person here. He did know about it but wasn’t too versed in the MPN world, and we worked together and I was on anagrelide and a couple of drugs and I was doing great, no problems. My platelets were good; everything was great for ten years. And then, things started to change. I started getting tired. And the first thing he said to me was, I think we ought to send you to MD Anderson.
When I had essential thrombocytosis, I felt fine. Emotionally I was fine because I had no symptoms. But when it started to convert, when things started to change and my lifestyle changed and I got much more tired and of course anemic, that was emotionally difficult. But then I went to see Dr. Kantarjian, and soon Dr. Verstovsek, who started me on different trials, I said I am not going to sit here and die. Because I got the same thing; five to seven years, not from any of the doctors at MD Anderson, let me clarify. But I knew that it was at that point kind of a death sentence, not to be dramatic about it.
But I was not going to sit back and let that happen. So I said, what can we do? And was told let’s start you on a trial. I’ve been on five. Three of them didn’t work. One emotionally almost killed me; it was not fun at all.
But the last two, I guess I could say I was in remission. I never heard the word from Dr. V, but I felt great. My life was going along fine. The last maybe six or eight months, the drug seems to not be working as well and we’re looking for something else, possibly stem cell transplant.
You’ve had quite a journey over about 19 years, so I’m guessing you’re really a guru to a lot of us; myself, being newly diagnosed compared to you. And I know that both you and Nick run support groups. And if I can ask you, since we’re talking right now, can you tell me a little bit about your support group and then Nick, I’ll go to you in just a few minutes. Your support group is in the Dallas area. Can you give me a little feedback about it?
Sure. It was actually started by someone, Karen Stern, a good while ago; I don’t remember exactly when. Unfortunately, Karen got very sick very suddenly and is no longer with us.
She had asked when she was ill if I could take it over for her. I said absolutely, I’d be happy to do that. So, we meet quarterly. We have anywhere from 15 to maybe 30 people that come. We talk about what’s new with us, what’s new with our symptoms, what reading we’ve done, how we have learned, what we’ve seen in all the different conferences, and we share a lot of information. We eat, we have a glass of wine, and it’s great fun.
It’s wonderful to be hooked up because as much as I think I try to keep up with the diseases, I learn something from people at our support group. What’s hard is when people don’t come anymore for reasons that they’re sick or other reasons, and that’s tough on the group. But it’s all part of the process, I believe.
We have a lot of communication; we talk to each other. We use Facebook and we learn.
Wow, and it sounds like you guys have a really personal group there and happy; that in-person connection sounds wonderful. Thank you. Nick, tell us a little bit about your support group in central Florida.
It’s definitely a little looser organization. We have probably an email list of about 15 people. We keep adding just about one person every other month or so. Unfortunately for me, we got the group together and I started just doing the emails, sharing information with people, guiding them to Patient Power, guiding them to MPN. A lot of them are trying to find doctors in smaller towns in Florida where they don’t have access to people like Dr. V, and so trying to steer them to some of the better doctors in the area.
Unfortunately then I was going through a transplant so I was kind of out of pocket. So we’ve not had a chance to physically meet. We are kind of spread out; we have people in Jacksonville, Orlando, Tampa, Miami, and Naples.
So just with my regrouping here after the transplant, we’re hoping to probably in the next month or two have our first face-to-face meeting and get some folks together, probably in Orlando, and try to get the group together. But so far, it’s just been a matter of emails; folks emailing each other back and forth. We do have a lot of it seems like mostly PV patients, and they will share different techniques and just like Andre was sharing, some of the things she’s been through. I definitely feel that being around other people who are in the same boat is so much more powerful because it’s hard sometimes to talk to your family members or friends or people at work because they just don’t get it.
They don’t understand what you’re going through and how scary it is. They can’t really give advice. So we’ve found that the support group has really been – it helps me as much as being a part of it is feeling better about what’s going on. It is kind of sad, too, as Andrea said as you see some of the folks take a turn, and you’ve got to kind of rally everybody together because it is – unfortunately, this group, it’s folks who are sick and they’re all going to have their ups and downs and we have to kind of be there for each other. So, it is one of the tougher parts of being a part of a support group as well; I agree with Andrea.
I can definitely imagine. Just hearing from both of you and my own experience being in a support group, whether it’s in person or whether it’s online or through email, they’re just all equally effective and really sometimes the best medicine for us; a certain part of our care. I’d like to shift gears a little bit, and Lindsey I’d like to talk to you a little bit with your expertise in the field. Patients are newly diagnosed and you know, how do you convey to them the importance of educating themselves and their family and their friends? What would your message be?
The MPN Research Foundation has extensive information on our website, and also when somebody registers through our online system.
And I’m not talking about the registry; just contacts us initially, we send out packets with information and we will customize those packets according to a specific patient’s need. We also do or best to hook people up with local support groups or many times people come to us looking for a doctor or a specialist, and we’ll point them in the direction of online resources or others who may be able to help them locally. We have lots of resources available to patients through our organization, and also on our website and to the extent that we can help with a specific question, then we usually try and point someone in the direction of someone else who can.
I have to say that that’s exactly what I did. I found your website when I was newly diagnosed and I registered. I got my packet. I was so excited, it had a lot of great information for me. I also got some wrist bands, and I just felt connected.
It was one of the first organizations I found and it just really gave me a sense of really being connected. So, Dr. Verstovsek, I would like to talk to you a little bit about how do you advise your new patients about identifying trustworthy info as far as… we could all go on the internet and go willy-nilly. I was convinced I was dying after two minutes on the internet. But you must get a lot of that. You must get patients asking you what do I do, how do I get information; how do you guide them?
Just towards my endorsement of what we have discussed so far in terms of education and the patients’ engagement, I have seen some of you in my own clinic and you know very well that to every new patient, because this is a chronic disease or diseases, the patients have to be engaged.
And I always endorse them to become a partner in what we are trying to do together to control the disease and eliminate the problems, and make people enjoy life fully for as long as possible with a good control in signs and symptoms. And therefore, engagement and partnership with your doctor and self education through support groups, through symposia, through pamphlets through web is increasingly important. Because the decision-maker is the patient, after all. The doctors are here to support.
And if they can partner together throughout their lives and become good friends, and I always seem to joke about it; we become good friends for the rest of the time. We actually do, and we engage together and we try to educate each other. I learn from the patients, patients learn from me and we go through life together. And so an educated patient is the one who is the best patient because we can participate together. And the sources are increasingly available to all of us.
What we are doing her today, Patient Power on the web, MPN Research Foundation through the web, through symposia, through pamphlets, through educational material, participating in patient symposia through educational foundations; those are also available apart from MPN Foundation. And then going to the academic centers and their websites; MD Anderson, Mayo Clinic, University of New York City. There are a number of very well established academic centers that have very nice academically-driven websites for education of the patients.
It’s not necessarily to engage at the professional level where the doctors would go and educate themselves about these rare conditions, but also the patient side of the academic sites are very well informative for the patients. This is where you get up-to-date information from very well established professionals that are engaging in education of the patients.
Plus, what you have described, Nick and Andrea, engagement at the personal patient level; support groups aerospace increasingly important for the understanding of the complexities that we are facing and understanding the diseases, and understanding the therapies and the different outcomes. Look at yourselves in this panel. We have a patient, Beth, who is an example of an extraordinarily response to a therapy in complete remission.
Nick had a progressive disease, ended up having a transplant; and Andrea has lived so many years with the condition and went through the different therapies with different outcomes and is living now way more than what her first doctor said about myelofibrosis; nine years and going very well. So, people are different. Things are improving markedly and we need to work together, and education is the primary source of that effort.
That is fabulous. I could really see how your really personal approach to caring and educating your patients really allays their fears. I wore those shoes where I was scared, and I really admire the way that you help your patients understand what is out there for them and to see the positive approach. Dr. Verstovsek, why do you feel an MPN specialist is so important when we have patients like Nick and Andrea and myself and others out there, as opposed to just kind of avoiding the specialists? What are the things that we should be really aware of and why we should go to an MPN specialist?
MPN diseases are rare diseases. And in many circles in academia, particularly essential thrombocythemia, polycythemia vera, ET, MPV are considered benign. Yet, we know that patients can change. Andrea has changed. There might be complications that can affect not just the quality of life, but the life duration as well.
Myelofibrosis is certainly much more aggressive and progressive, and can shorten life a lot but is the rarest of the free. So, myelofibrosis being so rare, people in a community setting, in smaller academic centers don’t have much experience. ET and PV, so-called benign conditions but not to me so benign, there is a need for education not just at the patient level but also at the level of physicians. There is much effort to educate professionals about the new developments in diagnosis, in therapy, and in prognosis of these conditions.
And therefore, a second opinion is always good to get. Wherever you are, even if you come to me as a first doctor, I encourage people, patients who come to me as a first doctor to seek a second opinion if it’s necessary to fulfill that educational potential that professionals can give so the patient is fully aware of what’s happening, and to live with that condition for the duration of time that there is.
The professional impact on the patient’s life is enormous because these are conditions that people live with. And therefore, proper indication and seeking a second opinion, and perhaps visiting an MPN specialist is highly encouraged
Doctor, how do you coordinate care from afar? If it’s just not geographically… someone doesn’t have an MPN specialist near them, can you tell us a little bit about how you would coordinate that?
This is an excellent question because the specialists are around the United States and as you aid, not everybody can be local or come very often. And therefore, communication with the local doctor and education through the email or the phone is vital. We try to form a team. Patients at my center know that we are not here just to provide one-time opinion; it is continuous engagement with the local doctor.
And the patients are always encouraged to come back at the frequency that can be absorbed by their social and financial status; every six months, every 12 months if possible with more benign conditions. Or, with more aggressive conditions more often; engage in what they do, developing new medications or advising on the proper use of standard therapies. Because it is not easy even for a patient in a community setting to apply standard medications properly because of the rarity of these conditions, particularly myelofibrosis.
So, a team effort with the specialist, with the local doctor, and the third most important is the patient themselves; fully engaged in these three triangular here will provide the most benefit for the patient’s outcome overall. And that can be done as necessary. But one thing is that sometimes I should say expectations from the MPN specialist perhaps are overshadowing what actually the expert may do.
For example, myself, I am not able to monitor patients from a distance; it’s not advisable. Therefore, the local doctor must be part of the team with the interaction through the ways that I described for the best outcome of the patients. But not one doctor that can be supervising patients wherever they are.
And that’s wonderful to know that this option is there for them. Because we do hear from patients who are in more remote areas and feel that perhaps are not getting the care for someone that’s really more renowned in their field. So it’s so wonderful to hear about those types of patient’s and how it can really benefit the patients. Thank you.
Lindsey, I’d like to ask you a few questions about the goal of raising awareness. Why is raising awareness essential to move forward, to really move research forward?
That’s a great question. You know, as most people on the phone are probably already aware, the MPN Research Foundation is very involved in funding research and trying to help direct research for MPNs. One of the things that we really need to try and understand is the course of the disease and how we can help to affect the quickest results for the patients to help them to feel better. I don’t know if that answers your question, but that’s one of the things that we focus the most on, and that’s where our projects are directed.
That’s great information. You know, I think people tend to forget that if we are such a rare group of diseases, the MPNs, and if we’re not raising awareness, we’re missing out. And we’re missing out in moving that research forward.
Nick and Andrea, Andrea I’ll start with you; could you just give me some ideas, maybe? Has your support group or you, yourself personally, thought of different ways to get involved to raise awareness?
Well, one of the things we’re trying to do is invite speakers to the meeting. And my hematologist came once, and it was on a Sunday; I thought that was a very noble thing to do. People got great information. No holds barred, he answered questions and it was great. And hopefully we’re going to have someone from Cancer Care so that questions can arise, and then people can go and ask about them and check. How to raise awareness, I think it’s talking to people, I think it’s participating in maybe the LISTSERVs. It’s participating in things like this where they tune in and hear things and ask their questions.
I think it’s part of it on Facebook, encouraging people to go to meetings and to get more educated.
Those are all great ideas. Nick, do you have a few ways or things that you’ve done either individually or through your support group that you try to raise awareness?
Yes. I was kind of fortunate in that several years ago I was president of a company headquartered here in Tampa called Beef ‘O’ Brady’s. We had 270 sports pubs, kind of like a Buffalo Wild Wings. And then more recently I have a company called Little Greek, and we have 33 restaurants. We have five or six in Dallas and 17 here in Tampa. So fortunately the local media kind of got behind me and they did several articles about my disease, talking about myelofibrosis, trying to help us find – we signed up 700 Be the Match folks. Because I was trying to talk about the importance of getting people in this Be the Match database.
And then my wife did a blog going through the transplant process; she had over 10,000 hits and we actually set it up where it’s in book form where you can order it on Amazon and we’ve given it out to folks as well. So, we’ve definitely been pretty proactive here in the Tampa market with the Tampa Bay Times and Tampa Bay Business Journal and the Gulf Course Business Journal. They’ve been very nice about covering my experience and some of the ups and downs, and going into transplant when you don’t know if you’re going to make it, and how do you set up your business.
So we’ve been pretty fortunate. But it is such a rare disease, I have to explain myelofibrosis. They say what’s that, and I say it’s kind of like leukemia but red blood cells. I know my primary doctor said Nick, in 17 years you’re my only myelofibrosis patient and probably before I retire, you’ll still be my only myelofibrosis patient.
Fortunately, people like Dr. V. out there, his videos were so helpful for me early on, and I really do appreciate the senior physicians in this field. They’ve been so gracious with their time to get out there and help educate us. It really blew me away to have access to those types of materials because there’s so many questions.
I really appreciate him even being on here today; it’s so impressive.
Great. Wow, Nick, that’s so encouraging to hear about how you and your wife got the community involved and really brought awareness to such a rare disease. Dr. Verstovsek, how broadly within the oncology community, how aware are they of MPNs? There seems to be other cancers and such that have a lot more attention.
Over the last ten years, much has been done on the awareness of these conditions for the physicians themselves. You may know that for example, one of the major meetings, the professional meetings in the United States is American Society of Hematology meeting that is always done at the beginning of December. And I tell you that ten years ago, there was no session on myeloproliferative neoplasms or MPN.
No educational sessions, no scientific sessions of significance of all; it was neglected completely. We changed the field completely from 2004 on by the discovery about what is problematic, the JAK-Stat pathway abnormalities, these biological abnormalities in all the patients and all the associated genetic abnormalities that leads to progressive disease. We changed the understanding of the disease. That led to development of new medications, developing new prognosis coding systems, improvements in our ability to manage patients. And now, I should be proud probably that it is not as fast as we would like, the MPN is at the same level as any other more serious conditions like acute myeloid leukemia. We have full fledged scientific sessions on MPN on its own, presentations, oral presentations.
I would say that people in the field, because this is relatively new, still, are hungry for information; the education sessions are full. Much more can be done on education of the physicians. So it is coming there, but it is a slow process, educational process on the patient side is in parallel being done to educational professionals.
Wow, that is great. And it’s encouraging to know that the MPNs are getting the attention that they should be getting. Lindsey, I wanted to ask you, do you feel that focus on MPNs are being overlooked because of more prominent advocacy with these other conditions?
I would say that it’s similar to what Dr. Verstovsek was saying. I’ve personally been at the American Society of Hematology meeting myself, and I’ve been at a lot of other – participated in some other meetings recently.
I’ve started to look more – obviously, given what I’m doing now with the registry project in the media, there’s definitely a lot more focus on MPNs than there probably once was. I also participate in some activities in Washington, D.C. having to do with the rare disease organizations there; there’s a few different rare disease organizations. So the MPN Research Foundation is trying to participate in activities like that to make sure there’s continued focus on MPNs there.
But you know, I think that we can never do enough, really, when it comes to a rare disease. We all have to play our part and keep it at the forefront of people’s radar because until there are better therapies out there, we can never stop.
Wow, and that is great to know that the MPN Foundation is really getting more focus with the rare diseases and the work you’re doing in Washington. In fact now, I’d like to show a quick little video. There are a lot of people in the MPN community around the world that support MPN awareness and they’re doing great things. This short video will give you an idea of who those people are out there. So, I hope you enjoy this video for a few moments.
Alright, so did you guys catch Nick in there? We’re hoping to hear from now we’re going to run out of slides because there are so many folks out in the community doing such great things, and that was real cool, Nick. Lindsey, I’m dying to ask you this question. myMPN Registry; we are all really super excited about this from the MPN Research Foundation. Can you talk a little bit and tell us what it is and what the goal is?
Sure, I’d love to, thank you. So, as we’ve talked about on this webinar, there’s a lot of different experiences by each patient with an MPN.
Some people live with it for a long time, some people get a diagnosis that comes out of nowhere and it advances quickly. There’s lots of different paths that can be followed by an MPN patient. And one of the things that we’re most focused on, as I’ve stated previously, is to try and get some therapies that can help the patients regardless of where they are on that pathway. We said to ourselves, how can we better understand the pathway itself because each person’s experience is different.
People have different symptoms, they have… some of their symptoms are in their blood counts, some symptoms are more depression or they may have itching, they may have some other brain fogginess; different things. Everyone has different combinations.
So we wanted to understand that, and what we decided to do was put together what’s called myMPN. It’s a registry for patients to go in and share their experience. And in doing so, they can help to change the prognosis of all patients. Actually in the slides that you ran, there was a quote from Helen Keller and it talked about it’s not just one major mover or shaker; it’s actually everybody in the process along the way. That really encapsulates what is going on with myMPN.
We need patients each to go in and share their individual experience. We would love it if they would not do it just once but many times; keep coming back to the registry. So, the registry is structured so that we gather the information in a primary survey that has some history, background about an individual, their diagnosis, a little bit about their history and treatment, the drugs or therapies that they’re using.
But then there are additional surveys that we invite the patients to come back and fill out again and again, which collect information about what’s changing. So, there might be an event that has affected their health. Maybe they had some sort of a thrombosis, or a pregnancy, or it could be something related to their MPN or something unrelated. Then there’s another third survey called How Do You Feel Today, and that’s where we really want to understand the patient’s whole experience with the disease; how did they feel today versus how will they feel next week. Are they getting sleep, are they eating? Are they having a lot of fatigue, are they itching?
The idea is that for the many patients that we gather this information over a long period of time, then that will start to help us to understand the diseases better and over time, hopefully we can figure out if there are triggers to the disease advancing from one stage to another; trying to help to put together some of the pieces of the puzzle that currently aren’t available to researchers in the labs and in the hospitals.
We’re hoping to augment the research that’s already going on by helping to provide those researchers and doctors with day-to-day experiences of patients. So it’s a really great way to involve the patients directly in the direction that research is having.
I think this is fabulous. Is this up and running now? Is it accessible?
Yes. We launched actually earlier this month in connection with Blood Cancer Awareness Month. I’m humbled by the response; it’s just been fantastic to see how many people have really been involved and engaged and coming back to the registry.
That is wonderful. How does someone get involved? How do they sign onto this?
We have a dedicated website for the registry; it’s www.mympn.org. And on that web page they will see the link through to begin the registry process. The first thing that a user would do is set up their privacy settings. We liked the platform for this particular registry setup because it enables each patient to customize their privacy settings.
Some patients are very comfortable sharing the information about their health history and background, helping to contribute that information toward the scientific process. Some people just want to record it for their own future reference, and that’s perfectly fine.
Either way, we’re just glad that people are getting engaged. The system, myMPN system, actually does have that flexibility so the patients can determine what information, if any, they’d like to share with the researchers and the research process. That’s the first step; you set up your profile for your privacy settings, and then as I said, you start to go into the survey where you talk about your history with the disease. And then we encourage you to come back and fill out the other surveys on an ongoing basis.
Great. Well, I signed up so I’m really excited that I can be a part. Dr. Verstovsek, I wanted to ask you, you’re on the steering committee of myMPN, one of the doctor’s registry.
What kind of impact do you think this is going to have for you and the way you practice medicine and make decisions and deal with patients over the next few years?
This is a very significant step forward. Look, what we know about the current conditions, like for example polycythemia vera. Let’s talk about polycythemia vera. You have in the literature assessment of the outcome of the patients that were referred to tertiary centers in the consultations. So they would come to Mayo Clinic, or to MD Anderson, or Moffitt or any other large academic centers. And there would be possibly let’s say 500 patients with polycythemia vera that were seen over the last 20 years.
Academicians would analyze them from the time they arrived and what happened with them with therapies, and you would come up with some knowledge. But that is such a small, small part of the larger community of polycythemia vera patients. There are possibly about 100-150,000 polycythemia vera patients living with the condition here in the United States.
And what does it mean to analyze the outcome of the 500 patients that were referred to you in academic centers? It means a lot, but not too much in the larger picture. So if we have a way of having a registry where multiple, multiple people, patients from – many patients from a larger group of patients, not just those that are seen in academic centers, can participate. And we can learn how they were diagnosed in a community setting; what did the local doctor do?
What symptoms did they acquire during their lives? What therapies did they receive, and why and what happened with those therapies? Any complications with the thrombosis? Any complications through the pregnancy? Those are the issues that are mentioned already. What led them to be referred to academic centers?
We can enlarge our knowledge, better our knowledge about the disease conditions; time to diagnosis, time to progression, management in community setting and the relevant new interventions and new ways of assessing needs of the patients, and understanding life with PV, or life with ET, or life with myelofibrosis on a larger scale and see where to intervene and how in the future.
And in some ways, this really seems to overlap personalized medicine. We’re now not looking at the one scenario for PV or myelofibrosis or ET. We are looking at hopefully a huge group of MPN patients and putting those pieces in the puzzle, as we said Lindsey.
And let me add – this is really good. This is an excellent comment. Because we these days think a lot about the genetic complexity. There are patients with myelofibrosis or any other conditions that differ based on genetics, as I mentioned earlier on. But there are patients with myelofibrosis that present with anemia only, patients that prevent with very big spleen and poor quality of life.
There are different ways of people progressing or presenting with a condition not only based on genetics. What is the experience of patients that have only low blood cell count versus those that have a very big spleen; how did they fare? It’s clinical assessment and quality of life assessment and blood cell count assessment. We don’t really need to engage in extraordinary tools to learn. Genetic is one part of it, but it is much more we can learn from our on practice on the larger scale.
Dr. Verstovsek, is there really a difference between this and an observational study?
There is some difference in that observational studies are usually much more focused in a shorter time period in a selective group of patients, in academic centers usually, with much more scrutiny of the detail. So, if you have an observational study in polycythemia vera, since we’re talking about polycythemia vera, there is such a study; it’s called the REVEAL study. There is also observational study for patients with essential thrombocythemia and early stage myelofibrosis called the MOSS Study.
So, a limited number of patients with very dedicated focus to see patients periodically, collect all the data of what happens to them all the time, because they are followed by clinicians and the researchers and nurses; this is a full fledged clinical study. Without intervention, just to see what happens with them; what symptoms develop, what complications they may have with other medical problems, what happens when they’re hospitalized and why, what the reasons are for intervention for their disease.
What is the effect on their work, ability to communicate with the family, engagement in social encounters. So it’s much more focused, perhaps more in detail and in a short period of time. But it does very well complement the registry, which is much broader and for a much longer period of time. So, I encourage patients to participate in both efforts.
There is complementation between the two, and certainly encouragement from the academic and local doctors to learn from these efforts.
Doctor, what is the criteria to participate in an observational study?
Unlike the registry where really we are trying to include everybody who has the disease at different stages to see what is happening with them, registries are usually focused on the patients like the Moss Study; I mentioned it’s for patients who have essential thrombocythemia that requires therapy; and for patients with myelofibrosis that do not require therapy. So it’s a concerted effort to understand much better in detail particular groups of the patients. So there is eligibility criteria for participation in some of these observational studies, unlike the registry where we really like to have everybody.
Alright. And of course now this leads me to clinical trial. We hear a lot about clinical trials. Could you briefly describe for us the difference between a clinical trial and an observational study?
Absolutely. And see, while I was giving an example of an historical analysis of patients in academic centers that leads to information how to manage patients and what to do about them. But these are the patients who are referred to academic centers, usually – most of the time – because they are not doing well and there is a need for intervention. And most of the time, we talk about treating patients that need to have something corrected.
They suffer from anemia, they suffer from a blood clot and this is where we intervene, and this is where most of the work in academia is focused on. This is where we do clinical studies. Clinical studies in MPN, most of the time and in the United States in particular, are focused on correcting something that is wrong; improving quality of life, decreasing the spleen, improving the anemia in ET or PV.
We would like to treat people for what they suffer from; high platelets, high red blood cell count, big spleen, symptoms. Intervention studies in myelofibrosis for example are needed as we try to prevent another clot in patients with ET and PV. So we are moving from interventional studies to prevention studies. And to get proper assessment of those patients in need, observational studies are needed to learn about the experiences.
A registry is needed to learn about a wide spectrum of patient experiences for us to identify groups that would, for example, benefit from prevention rather than waiting for them to suffer and then prescribe something to correct it. So prevention studies will be major developments, in my view, from observational studies to see where we need to intervene once we observe.
Very interesting. I had not even heard of that. That is fabulous.
Both Nick and Andrea, you have both participated in trials. And Andrea, I would like to go to you first. You’ve been in several clinical trials. What was your journey, and what was beneficial in participating in those?
Well, frankly the whole point of my participation was not only to feel better and maybe arrest the disease to an extent, but I felt since it was such a rare disease I had an obligation to try to advance research by using me as a live guinea pig. Instead of donating my body to science later; let’s try to do something now. Of course I had selfish reasons, as well. What happened with the early studies which were done nine years ago or so, several of them just were very toxic for me, and for different reasons.
But different things happened; a couple landed me in the hospital. But I knew there was something out there, working with Dr. Verstovsek, working with my local hematologist; I knew that if I didn’t try and didn’t do things, that I certainly wasn’t going to get any better. So, when we hit on CYT387, which I bugged Dr. Verstovsek about because I read about it, and I said it sounds right for me; he said yeah, I’m gonna get it, I’m gonna get it.
He finally did. It worked for five years. The company was bought out by another company. I have a similar drug; it doesn’t seemed to have worked as well but for five years I’ve been transfusion independent, which is huge.
While my anemia has not been anywhere near normal, it’s certainly functional and I’ve been great. Now we’re looking for something else. I’m a perseverant person, and the first couple of trials didn’t work but I didn’t die, and I didn’t get any worse. And the fourth and fifth trial did work, so I think I have to encourage people to not give up. We’re all different, and we talk about that in our support group. Everybody is different. We are so individualistic in this disease that we can listen to other people, but we have to really listen to our bodies and ourselves.
So now, it’s that period of kind of treading water; what do we do next? There are some things that Dr. V has mentioned, there are some things that I’ve been reading about that I’m going to quiz on him when I see him next. And so it’s a little discomforting right now because something has to happen.
But I’m confident and positive that there will be something out there, but if I don’t try, we’ll never know and a patient behind me – we have people in our group who are 20 years old and 30 years old. They’re panic-stricken. So hopefully I can help them, maybe; if I don’t someone else does.
You know, Andrea, you’re very inspiring. Me kind of being new to the game, too, it’s very inspirational to hear about your perseverance and your attitude. I love the idea that you’re also there for the younger people in your group to show that this is the journey but it’s working, and there’s hope on the horizon. Nick, if you could tell us a few things, a few thoughts about your journey through your clinical trial and if there was a benefit?
Yeah, sure. It’s kind of interesting for me initially when I was diagnosed, the local doctor said well, you’re so lucky; you have Moffitt right here in your backyard. So I went to Moffitt Cancer Center, and they’re very good but the hematologist said basically the same thing that the initial doctor who did the diagnosis; well, you’re a good candidate for transplant, just wait a year, watch and wait a year and then go to transplant and so be it. But you do the research, and transplant is a pretty tough deal.
When I went to Moffitt, basically that’s what the doctor said, is we’ll see you once a month or every other month and sometime next year you’ll go to transplant. I said doctor, I can’t just sit around and wait and just sit back and placidly have this ticking time bomb hanging over me without trying to do something. And like Andrea, I also felt I owed it to the other patients that maybe being part of a trial that we’ll learn something.
I was hoping – my goal was to try to postpone my transplant for several years. But I said being part of the trial, maybe they’ll learn something good or bad that will help other patients as well. And that’s where I was very fortunate to land at MD Anderson with Dr. Pemmaraju.
They set me up on azacitidine and Jakafi. Moffit’s pharmacy doesn’t even carry Jakafi. So, the No. 1 tool in the toolbox for MPN patients, they don’t even have it there. That’s where we did the trial, and I think with the trial the one thing that people need to know, you’re under a much higher level of scrutiny. Dr. Pemmaraju at Moffitt, they’re having me come in every 30 days for blood work, 60 days to visit with the doctor. Pemmaraju, he’s seeing my stuff every week; they’re looking at my numbers. I go fly out there once a month to meet with them.
And so you have an extra layer of coverage. And ultimately, it was Dr. Pemmaraju who said hey, Nick – by the way, CAL-R, JAK2 was my mutation, which also people need to know who’s doing what. But in October, Dr. Pemmaraju noticed my BLAST had spiked from 1 to 5. He said Nick, you’ve got to go for transplant because if it turns into AML, your prognosis really gets a lot worse.
And I’ll always remember the look on his face. He just looked at me and said, time to go. That’s why I think his higher level of watching me gave me that sense because there is some controversy out there as to when to go to transplant. When do you go? Do you wait? Is there a certain number you have to hit?
I felt that his advice, based on all the doctors I had met with, was very right on point and I appreciated their – there’s a great group of folks there, and I certainly think that my success – and I don’t know if Dr. V. agrees, but me being on Jakafi, actually they kept me on it through the transplant; I think that helped me because I’ve had a fairly good transition through the transplant process. And I think it was based on the work that Dr. Pemmaraju did.
Great. Nick, you’re very encouraging. Dr. V, since Nick brought that up, how do you feel about that, that he was kept on Jakafi?
I would say that both Andrea and Nick have amazing stories to say and to tell us their experience and to learn, and really inspiring stories. I’m glad that there was a time period to enjoy some good quality of life and control of the disease for Nick. But in this tough disease, myelofibrosis, it can be controlled for a long period of time but it does change as the medications really don’t work forever. And sometimes it is necessary to go to transplant and we treat patients up to the transplant with Jakafi to maintain the benefit that might still be there.
After the transplant it’s not necessary anymore, of course. But that is one of the experiences that people need to understand that there is a potential for medications to control the disease, either through clinical studies and the first option may not work, the second may not work and there are always – and we try to have those here – multiple other options through conventional medications or through investigation medications to help patients. And if the transplant is necessary, we will do it when the time comes and it is a personal decision most of the time.
It’s not really one number; it has to be between the physician and the patient.
Absolutely, absolutely. Lindsey, I’d like to ask you the last question, and we do have a few questions from our viewers. We’re talking so much about clinical trials and raising awareness, how do we do that, and how does raising awareness affect the clinical trials? I know like barely anything about clinical trials.
Sure, that’s a great question. In fact, one of the things that we try to do at the MPN Research Foundation is to let people know about clinical trials that are going on so that to the extent that someone is looking for something better, kind of like Andrea was or has been. Maybe they haven’t been made aware by their own doctor of an ongoing clinical trial.
And by using our social media and our website, etc., we can make people aware of that. I think that’s – it’s a great way for people who are patients but also I think that it’s important for patients to understand the message that Andrea delivered that I think was so eloquent. Which is unfortunately, drugs don’t come onto the market without brave patients like Andrea and Nick who are willing to put themselves out there and take something that is yet to be approved by the FDA. Because the FDA has very specific standards and they scrutinize the trials very carefully. But at the end of the day, we need patients to volunteer for these trials.
I think it’s wonderful when patients do that, and it’s even better when the results are great, obviously. But I think from an educational standpoint, we as an organization and I know others try and help people to understand what their options are, what the process of a trial is. We’ve actually in the past put together graphics to help people understand how trials progress. We actually have been involved ourselves in discussions with the FDA on how trials can be more focused on the patient experience.
So I think that things are definitely going to improve, and hopefully we’ll see more drugs that are available for patients that will provide more relief very soon.
That’s very encouraging. I absolutely agree with both of you how people like Nick and Andrea, and could be myself as well one day in the future; we can’t move forward. We don’t want to be stuck and not be able to have those results. I’m going to shift gears a little bit. We’re ready to take a question. Dr. Verstovsek, this question I believe is geared for you, and I’m going to go ahead and read it. Dolf from Holland is watching.
How is research internationally organized? Dolf goes on to say lots of trials with MPN hematologist around the world, and we can find them on clinicaltrials.gov. But is there also some specific research in some countries that’s not registered at that site? Is that something you can address?
That’s a very good question. There is an attempt by clinicaltrials.gov, which is actually the federal site, to collect all the clinical trials that are being conducted not just in MPN, obviously, but in any other condition. And the effort is really significant with the prospect of utilizing that for patients as well to identify the sources, if not only for the physicians. It is really the professional side but the patients can search that as well. Perhaps it’s too cumbersome sometimes to find information, but underlying the attempt is very well received at least in the professional circles.
If there are any other studies in other countries that are not registered, of course it’s a possibility this is the Federal Government of the United States. I am not aware, didn’t really look into that, whether other governments in Europe – and I would say some they do, maintain something similar for their own countries like in Germany or France.
This is, after all, one of the best sources of information, clinicaltrials.gov, for clinical studies.
Great, thank you so much. We’re going to take one more question; unfortunately we’re almost out of time. But we have another event coming up October 7, and we will definitely answer many of these questions that have come through tonight. And in fact, Dr. Verstovsek will be on that panel as well, on the upcoming one. I do have another question for you, Dr. V. It’s from Julie. Do you have any tips for patients to educate their primary care provider about MPNs? And she said more specifically, PV.
The information that is available to the patients through the MPN Educational Foundation or through the information that can be gathered from the academic websites for the patients typically is organized very well for anybody to understand it.
I have patients that are engaged with us together, as we said, in that educational effort for all participants to be at the same level. That means not just us in a referral center or patients, but also referring doctors. So the best information to a primary care doctor, and I assume that was what the question was about, the local oncologist; that is delivered by us as experts in MPN and by the patients.
By bringing that information to the attention to a local doctor is valuable. There is rarely any doctor that would not appreciate so much the involvement of the patients on the part of education, and bringing the new information to the doctor. Look, the local hematologists and oncologists, that’s a hero for me.
That doctor, a female or a male, has to take care of not just the PV; it has to take care of patients in brain cancer and kidney cancer and lung cancer; both of the perspective of life and professional commitment in front of you for that particular doctor. That is the doctor that is doing all of this at the same time, and has to catch up. So we have to also realize that it’s really difficult to follow all the updates and all new developments in the field for PV or any other MPN. So, I know that doctors appreciate when the patient is engaged and brings information to them.
Excellent advice. Julie, when you asked about their primary care providers as well, I’m sure Dr. V. feels the same way; we can take a look at Andrew Schorr and his wife Esther who created and head up Patient Power. Esther is very vocal about being a very educated care provider.
And through everything we’ve talked about today with myMPN registry or the MPN Research Foundation, or all the things that Dr. Verstovsek brought up about how he educates his patients, the primary care providers definitely should be in that conversation. Those things are all welcome.
Well, we are just about to wrap up. We’ve had a really great discussion here today, and I would like to get some final thoughts before we say goodbye. We are a little pressed for time. Nick, if you can give us a few quick, final thoughts and we’ll just go around after that.
Well first, Beth, great job on the hosting. It was very impressive, and glad to be able to participate. And certainly want to thank all the panelists to try to keep moving folks forward. And hopefully some day the people behind us won’t have to worry about the same issues we’re dealing with today. And appreciate Dr. V. taking the time especially, and all the great work that his team is doing, too. So, wish everybody the very best, and thanks, and great job, Beth.
Thank you, Nick, and right back at you; it’s been a pleasure having you. Andrea, some final thoughts from you?
Yes, thank you everyone for participating, it’s been great. It’s my first time. I would like to say that one thing I found successful was to print some pamphlets up and to distribute to my doctor and leave them out so people are aware of our meetings. And also, to really encourage people to look very seriously into clinical trials and going to an institution like MD Anderson that specializes in their disease so that they can get the best care and educate themselves the best.
Thank you, Andrea. Those are great words of wisdom and we appreciate all of your feedback, having been in this journey for almost 20 years. Lindsey, can you give us a few final thoughts?
Sure. Thank you very much for including me in this conversation; it’s been wonderful to join Dr. Verstovsek and Andrea and Nick.
I encourage anyone who has not yet visited myMPN to please visit us at www.mympn.org. If you have any concerns or questions, please don’t hesitate to reach out to me. I encourage everyone, like Andrea said, to try and get involved in your care, whether that’s through myMPN, through joining a clinical trial, and certainly just being an advocate for your own health and going to go visit those doctors armed with the information that you can.
Thank you. Great words of wisdom. And again, we are very excited about the myMPN registry, so thank you for sharing that today. Dr. Verstovsek, we appreciate you being here. Some final words that you can give to our audience?
I really appreciate you having me on the panel; it was a wonderful experience.
And certainly what we have achieved together, I’m sure for many patients is to engage, engage and be educated, learn about what you have, learn about the abilities to help you if you are not already. Be an active participant because these conditions are there to stay with you; we don’t have a cure yet. We are working toward it. But life can be good, life can be controlled well. We have means and we are trying to do our best. So be an active participant with the local doctor, with expert. Make the most out of it and if you need a second opinion, search for it. Basically, do not give up. Be your own advocate, if you like.
Wonderful, and I couldn’t agree with you more. It’s just very inspirational and those words will resonate with many of our viewers, I know.
Thank you, I’ve enjoyed speaking with such experts on this panel today, and thank you for the words of wisdom and best of good luck and health to all of our viewers, and Nick and Andrea. Thank you.
For survivors Roberta Alberle and T.J. Sharpe and so many others, cancer was an unwelcome intruder that suddenly demanded their attention. Both became proactive and engaged, vocal patients, doing research about their treatment options and gaining access to clinical trials that made a HUGE difference.
Watch to learn:
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Understanding Treatments for MPNs: Are There New or Emerging Treatments That Could Be Right For Me?
What new treatments are in development for myeloproliferative neoplasms (MPNs)? What are the considerations when choosing a treatment plan? In this LIVE webinar, Dr. Bart Scott from Seattle Cancer Care Alliance and Dr. David Snyder from City of Hope will help viewers to understand the various treatment options for those living with polycythemia vera (PV), essential thrombocythemia (ET) and myelofibrosis (MF).
Hello and welcome to our Patient Power webinar today. Our topic is “Understanding Treatments for MPNs; are there new or emerging treatments that could be right for me?”
I’m Beth Probert, and I’m coming to you from Oxnard, California which is just northwest of Los Angeles. I am a polycythemia vera patient and patient advocate. I was diagnosed in April, 2016 by my specialist at the University of Southern California Norris Cancer Center. I was treated with Pegasys, which is pegylated interferon and a few phlebotomies for about 12 months. And I am happy to say that I am in remission.
But like many of our patients and caregivers in the Patient Power community, I am very concerned about the future of my condition and very interested to hear today about some of these new and emerging treatments and clinical trials that will give us hope for our future and for all of is in the MPN community.
Before I introduce our panel today, I do want to remind everyone that you can submit your questions and we will try to address every question in today’s show. If we don’t get to it, we certainly will address those questions in future webinars. You can submit those questions to MPN@Patientpower.info.
All right, I’d like to introduce our panel today. Joining us today from Seattle we have Dr. Bart Scott. Dr. Scott is a medical oncologist at the Seattle Cancer Care Alliance and a research associate in the Clinical Research Division at Fred Hutchinson Cancer Research Center. Thank you so much for joining us today, Dr. Scott.
Thank you for having me. Hello, everyone.
Great. And I’d like to introduce our other doctor on the panel today, Dr. David Snyder. He is joining us from Duarte, California which is in Los Angeles County. Dr. Snyder is an Associate Chair in the Department of Hematology and Hematopoietic Cell Transplantation at City of Hope. Dr. Snyder, I hope I said that correctly. Welcome.
Thank you, I’m happy to be here.
Thank you. Now I’d like to introduce you to our patient panelist. Today we have James from Lubbock, Texas and James was diagnosed quite a few nears ago with the central thrombocythemia. James, welcome to our show today.
Hello and thank you.
James, I’d like to start with you. How long ago were you diagnosed with ET?
In October of 1994, I was 47 years old. I had a heart attack. If it had not been Monday morning and I was in the hospital visiting my mother, I would be dead. I had a blockage right at the aorta. But they pulled me out of it.
I’ve been active all my life. Even back then, I was running more than I do now. It just happened to me, and so eventually we got around to essential thrombocythemia, whatever that meant.
Well James, that’s such an interesting story because you’ve been dealing with this for several years. And in 1994, if I’m correct, we didn’t really have too much internet access. How did you and your family deal with this? How did you get information and educate yourself?
Well, just so you know, I’m 545 miles from Houston, 325 miles from Dallas, in a town of 250,000. But luckily, we have a medical school. And so I went to the library at the medical school and I befriended one of the librarians whose husband was an oncologist, or is, and she was very helpful in trying to guide me. But back then, there really was very little information.
It wasn’t current. It was from the polycythemia vera study group, and that’s real old data and things like that. But when the internet came on, I started playing around on Yahoo, came across MPN – or back then it was MPD – Digest, and read that franticly every night.
I can certainly imagine what a revelation that was to all of a sudden have information at your fingertips. If I’m not mistaken, when we were speaking earlier you mentioned that you also through the years have attended conferences. Can you speak a little bit about that?
Yes, it’s literally empowering to go – and my first one was in 1999, but to go into a room and find other people who are dealing with some kind of MPN. I was like wow; I really am not quite so alone. And over the years the quality of the information has increased tremendously, as it has in the whole field.
It’s still empowering. I have friends I’ve made by going to the Scottsdale conferences; you just learn a lot. It’s just good.
That’s very inspirational. I kind of want to shift gears a little bit here and ask you a couple questions. Do you see a specialist?
I see a hematologist/oncologist in Lubbock and I have right from the start. He started me on hydrea and soon to be 23 years, I’m still on it. I’ve varied my dosages from time to time, but I’ve seen no need to see what you would consider an MPN specialist. While hydrea is working, I’m goin to stick with it and when it doesn’t, I’ll start looking around and doing other things. There’s no one I would consider an MPN specialist in Lubbock. I’ve talked to some oncologists and I had to alert them about anagrelide. I would say they don’t quite understand Pegasys versus the normal interferon and things like that.
But that’s really kind of been immaterial to me so far because hydrea is working.
And you do have that challenge of being a little bit more remote, and I can certainly see how that makes a difference. I want to ask you one last question. You’ve been on hydrea a very long time. Do you have any side effects?
None really. My wife says I’m just not quite as wired as I used to be. But the things I read about, the possibilities that could be occurring, I don’t have to. I don’t know why; I just don’t.
That is fabulous news.
As a matter of fact, the doctors don’t know why either. They’d like to know; I would too.
Sometimes there’s just no explanation. James, I really appreciate getting to understand your story and we’re certainly going to come back to you and learn a little bit more about your journey. I’d like to go over to our doctor panel now.
I’m going to start off with Dr. Scott. We’ve heard a little bit about James’ story, and for our viewers could you explain a bit about ET; just help us understand really what it is and more importantly, what are we treating it with and what are the goals of treatment for ET?
ET stands for central thrombocytosis or essential thrombocythemia, so it’s been called both of those names but the principle issue is overproduction of platelets. When you see the blood counts of the patient with essential thrombocytosis, their platelet counts are elevated. There can be a wide range of how elevated we’re talking about; it could be anywhere from 650 to even greater than 2 million.
When you have a platelet count that’s really high, like above a million, paradoxically there’s an increased risk of bleeding. That’s because the platelets have, on their cell surface, what’s called a von Willebrand factor cleaning protein. It actually cleans a portion of the blood that helps in clotting. So even though they have all of these platelets, and we associate platelets with preventing bleeding and bruising; when the platelets are extremely high like that, patients can have bleeding like nose bleeding, gum bleeding.
But the real problem with essential thrombocytosis is clotting. The No. 1 cause of death in people with ET is due to blood clots. And so James was just saying, he presented with this basically heart attack that he probably wouldn’t have survived if he hadn’t been in the hospital already. That can be a common presentation that you see with essential thrombocytosis blood clots.
So the reason to treat patients with essential thrombocytosis when they are treated is to lower their risk for blood clots; to lower the risk for thrombosis. The standard therapy for ET would be aspirin, a baby aspirin a day, and then you look at different types of risk factors to determine whether or not they need cytoreductive therapy. Cytoreductive therapy is basically given to lower the blood counts.
The risk factors that we would look at age, would be history of prior thrombosis, also white count is another risk factor that’s come out recently that can predispose people for risk of blood counts. But there is a prediction model; it’s called an IPSET prediction model and it’s an international prognostic model to determine the risk of thrombosis in patients with ET. You can look at that and you can see what risk factors this patient has.
Interestingly, JAK2 mutations, so having ET with a JAK2 mutation is another risk factor for thrombosis. But if they are high risk for thrombosis, either due to age or history of thrombosis, other risk factors like cardiovascular risk factors or due to the IPSET model, these are patients that are treated with cytoreductive therapy. There are many choices for cytoreductive therapy and two of them have already – actually, three of them have already mentioned.
That would be hydroxyurea, which is a common agenda that is used; another choice would be pegylated interferon or Pegasys; and then another choice would be anagrelide. There have been two randomized trials that I’m aware of comparing hydroxyurea to anagrelide. One showed a benefit with hydroxyurea over anagrelide; the other one was basically equivalent. But for me, my preference is hydrea unless they are a younger patient.
And in those patients I typically prefer Pegasys. I think there’s more data that’s needed to determine whether hydroxyurea or Pegasys would be the best first choice. There is a randomized trial that either has completed accrual or will soon complete accrual where they compared hydroxyurea to pegylated interferon; it’s frontline cytoreductive therapy for people with PV and ET. That will help us to answer the question which is better between hydroxyurea or pegylated interferon. But both of those would be choices for initial cytoreductive therapy.
Recently one of the big things that we’ve learned about with all myleoproliferative neoplasms is the underlying driver mutations. All of the myeloproliferative neoplasms share in common up regulation of the JAK-STAT pathway. And the same thing of course is true with ET.
And so there are three common mutations seen in ET: JAK2V617F would be the most common, and then calreticulin and then what’s called the MPL mutation. So you would test your patients for those mutations if you suspect a myeloproliferative neoplasm. They’re helpful not only from the standpoint of diagnosis but also prognosis. In regards to what’s coming out in the future, there’s a lot of understanding of other things that determine risks.
So as James was mentioning, he’s done well for such a long period of time. And then there are other patients who have more rapid progression to myelofibrosis, for instance, with a diagnosis of ET. We are looking at that and we’re starting to understand more about why that is the case. One of the things that have come out is what’s called secondary mutation that can develop in patients that potentially increases their risk of going into leukemia or myelofibrosis.
Wow, that’s been really helpful to understand. When you hear James has done so well for 23 years, the same medication, some fluctuation in his dosing, do you see that often? Do you have in your patient group; have you seen people have that same success as James? He kind of joked like nobody knows why I’m not having so many side effects and I’m doing well; what’s your take on that? Is that an anomaly or do you see that?
We do see it, for sure and I will admit I’m what we call a tertiary referral center, which means I tend to be referred cases that are more recalcitrant that have failed other types of therapies. Among the patients that I see, I do have somewhat of a swayed pool of patients that typically have more severe presentations, more severe problems, that don’t respond as well to initial treatments and have more of a prolonged course with side effects and things like that.
But that just has to do with the nature of my referral base. But certainly among MPNs itself, there are many patients who do quite well with hydrea for many years.
Great feedback; thank you, thank you. Dr. Snyder, I want to talk to you a little bit about myelofibrosis. As I mentioned earlier, I have polycythemia vera and I do from time to time get a little concerned about progression. We’ll talk a little bit more about progression in a bit, but could you talk to us about myelofibrosis and give our viewers a summary of it, and also address the treatments and the goals of the treatments through the different therapies?
Sure. So we’re talking about the family of myeloproliferative neoplasms, and we started with ET; P vera of course is the other.
The third type is myelofibrosis. What we call primary myelofibrosis is patients who are diagnosed right from the beginning with myelofibrosis. But we know that both P vera and ET have the potential to transform over time to what we would call secondary myelofibrosis, meaning that they started with one condition and over time it transformed into myelofibrosis.
We see certain changes when that happens. As the name implies, there’s increased scarring, scar tissue in the bone marrow; that’s what myelofibrosis means. We tend to see decrease in some of the blood counts, particularly the hemoglobin with anemia and often the platelet count. And at the same time, often the white count is normal or it can be very elevated.
One of the clues for a patient with P vera for example, is say a patient was requiring a certain frequency of phlebotomies to maintain control of hematocrit or a certain dose of hydroxyurea and after awhile the doctor notices gee, we haven’t done phlebotomy in about five, six months and still the hematocrit hasn’t gone up.
Or, we’ve been on a certain dose of hydrea for a long time and everything has been stable, but now it looks like the hemoglobin is starting to drop. That’s the kind of clue that maybe it’s beginning to transform towards myelofibrosis and the bone marrow no longer is over producing red cells, but instead there’s a decreased production of red cells.
So along with that comes a number of other features. The spleen often enlarges around that same time and people may become aware of that enlarging organ in their abdomen. It may impact their ability to eat. There are also a variety of systemic symptoms that can occur. Sometimes we see this in patients with P vera and less so with ET/, but most commonly in patients with myelofibrosis.
Those are things like fevers, weight loss, night seats, fatigue, itching, and others. That’s kind of the clinical picture that you see when a patient either starts right off at the beginning or is progressing. So in terms of goals of therapy, there are a few issues. One, just like with the discussion about ET, patients with myelofibrosis are at increased risk for blood clotting and sometimes bleeding, as well. But our main focus is to help prevent blood clots from occurring. And so the same kind of baby aspirin is needed, is used.
In addition, there is a treatment called ruxolitinib or Jakafi is another name, that is FDA approved for treatment of patients with myelofibrosis. I’ll say that’s the only drug currently that is approved by the FDA for myelofibrosis, despite the fact that there have been many clinical trials that we may talk about with other drugs. But ruxolitinib was approved based on two main endpoints. One was a significant reduction in the size of the spleen for patients whose spleen is enlarged, with relief of symptoms from that big spleen. And second was control of some of these systemic symptoms that I mentioned. Those are the two main benefits that people can achieve.
There may be some other benefits such as gain in weight for people who have maybe lost weight. There may be some prolongation in survival; that’s a little bit of a soft call but some patients may benefit that way.
So that’s the main treatment that we think about for patients with myelofibrosis.
It sounds like from what you’ve described and of course what Dr. Scott described is the symptom burden is a big driver in how you’re going to treat patients and the symptoms are also a big indication of if it’s progressing, if it’s doing what it should be doing. You’ve both mentioned a little bit about some of the mutation. In previous programming, you’ve both talked about genetic testing. My next question is when someone is diagnosed, and I know when I was diagnosed with polycythemia vera, one of the first things that was done is that I was sent to the lab to get some genetic testing.
How important is genetic testing in both of your views? I’ll hop over to Dr. Scott real quickly. At what point are you suggesting genetic testing? Is it something you regularly do?
Thanks for asking. So, it is part of the recommend workup now for myeloproliferative neoplasms; that all patients have this testing done. It’s important to realize that we’re talking about acquired mutations that occur in the vast majority of people. When the word “genetic testing” is thrown out, there’s this automatic misunderstanding that it means that it’s something that was inherited.
The reason why that’s important is because we don’t necessarily want to convey the false message that having a diagnosis of MPN means that your kids are going to get it, because that’s not what we’re talking about with this genetic testing.
These are acquired abnormalities in the vast majority of patients with MPN. There are very rare inherited cases of MPN that have been recorded, and in the vast majority it’s something that you acquire; it’s not something that you were born with. These mutations up regulate expression of a particular pathway in your body that’s called the JAK-STAT pathway.
There are three defied mutations to date, and they are JAK2. There are two different types; there’s the exon VC617F mutation, which most people with PV have, most people with MF have and most people with ET have. But there’s another mutation called the JAK2 exon 12, which is primarily only seen in PV.
That accounts for the small proportion of PV patients that don’t have the JAK2V617F. Those are the two mutations in JAK2. And then there’s an MPL mutation which can be seen in myelofibrosis, and in ET. Then the third mutation is what’s called the Calreticulin mutation, which is the newest one that’s been described. That’s seen in about a quarter of ET patients and about a quarter of myelofibrosis patients. Those are the three driver mutations that people acquire that’s been associated with myeloproliferative neoplasms. It is now part of the diagnostic workup for these diseases according to the revised World Health Organization criteria.
So that’s part of what we mean when we say genetic testing. That’s actually not the whole picture, because there are new types of mutations that have been described that I was talking about earlier that we believe are secondary events.
They have been associated with worst prognosis, higher risk of going into leukemia, and higher risk of going into myelofibrosis. One of those that has a negative prognosis connotation is what’s called the ASXL1 mutation. If you have that mutation, there’s data showing that these patients are at higher risk of complication like progression of myelofibrosis and like progression to leukemia.
So, I think that all patients should have mutational testing, what I’ll call mutational testing instead of genetic testing. And I think it’s important not only from the perspective of making the diagnosis but also in regards to prognosis. And honestly, it also helps a little bit with therapeutic decision-making. Because we know that ASXL1 mutations have a very bad prognosis, and that might be a patient that you would consider more aggressive interventions in, like stem cell transplant, for instance.
Thank you. Dr. Snyder, PV; we’ve talked about ET, we’ve talked about myelofibrosis and kind of flipping back to PV, when you find out that someone is positive and has a mutation, and let’s backtrack just a little bit. I realize I really didn’t delve into what PV is. Could you give our viewers a little background on PV, and then we’ll talk a little further about how the mutation plays a role with that and what we look for in that.
PV is polycythemia vera. It’s an over production of red blood cells. It shares the properties with its cousins, ET and myelofibrosis, the JAK-STAT pathway is over activated, usually because of the JAK2V617F mutation. So the cells in the bone marrow produce red blood cells become autonomous, if you will; they’re always turned on.
Normally the body regulates very well how many red cells are produced by the bone marrow. If the tissues in the body sense that there’s not enough oxygen coming and the message gets sent through a hormone called erythropoietin goes back to the bone marrow, stimulates more red cell production. More red cells bring more hemoglobin, brings more oxygen to the tissues and then erythropoietin production is turned off.
In P vera, that production of red blood cells becomes independent of the erythropoietin signal so those precursors are always churning out red blood cells, even though the body doesn’t need them. So the hemoglobin hematocrit can go very high, and that gets people into problems with risk of thrombosis as the main issue. Also, there are systemic symptoms that we talked about in myelofibrosis can also be seen in polycythemia vera.
So the treatment goals there are to again control the risk of thrombosis by keeping the hematocrit at a safe level, and there have been some well designed trials now showing that keeping the hematocrit under 45 percent is the desired goal. Some hematologists would even be a little more blasé about it and say well, it’s under 50 percent; that’s okay. But there are now clear data to show that you’re doing a disservice to your patient by allowing hematocrits to get over 45 percent. And frankly for women, it may even be better to shoot for 42 percent as the target.
And so the question is how do you get there, and phlebotomy is certainly the most direct mechanical way, if you will, of doing that. But cytoreduction with interferon is one option; hydroxyurea is probably the most common drug used in that setting.
And now for the last few years, ruxolitinib is also FDA approved as a treatment for patients with polycythemia vera who have become intolerant to hydroxyurea or resistant to it.
Great. A couple of questions here, Dr. Snyder; how do you decide who gets what? For polycythemia vera, and I myself have seen this; I’m a member on so many different focus groups and such, and I see that there are people, one is getting Pegasys, one’s getting ruxolitinib, one’s getting hydrea; how do you decide who gets what?
The first question is does the patient need any of those drugs? We stratify patients with P vera into risk groups depending on age and the presence of other traditional cardiovascular risk factors or history of stroke.
But for a young person, say someone under 60 without risk factors, they can be maintained with baby aspirin and an occasional phlebotomy from time to time to maintain hematocrit under 45 percent. And they could go potentially for many years with that approach very comfortably.
The times that we say the cytoreduction is needed, there are a few things. One if it’s a higher risk patient, say over 60 with history of a stroke, other cardiovascular risk factors for example, or a patient who has other change sin their blood, not just the high hemoglobin but now maybe the white blood cells and the platelets are going higher, and also maybe the spleen is starting to get big. Phlebotomy is not going to help those features. That’s the time where you would start considering cytoreductive therapy.
We mentioned interferon, and Pegasys is the form of it that we now use. I do consider that more in younger patients because it’s a drug that may be harder for older patients to tolerate, so that’s the starting population. As Dr. Scott mentioned, there are trials going on to kind of compare head to head hydrea and interferon to see is one maybe better than the other. There are some suggestions that interferon may accomplish more than hydrea could in terms of some of the disease parameters. That’s not clear yet from the studies.
So that’s an option in a younger person. Hydrea really still is the main go-to drug for most patients who need cytoreduction. And then ruxolitinib, as I mentioned, it’s only FDA approved or indicated for patients who have already been on hydrea and have been either resistant to it or intolerant to that drug. So you can’t use ruxolitinib as frontline therapy.
The insurance companies won’t pay for it, and as we all know it’s a very expensive drug.
That’s a very, very common thing that we do here. We talked a few minutes ago about the mutations and doing some testing. Dr. Scott, I want to go back to you. How often do you suggest that patients have the initial genetic testing? I have found out that I’m a little unique compared to some of the other people I’ve been talking to about the frequency of genetic testing. So, how often do you suggest your patients get the genetic testing, Dr. Scott?
I’m going to be honest with you; that’s a very difficult question to answer in a definitive way, because there’s really a lack of data to address the question that you ask.
And so, I think it’s a personal decision that I assist my patients in making in conversations with them. There are a lot of different factors that go into answering that question. So, first I’ll say that everyone should have it at diagnosis, and I think most people would agree everybody should have an extensive panel sent at diagnosis to not only include the three driver mutations, but also the associated mutational changes that can be seen like ASXL1 and EVH2.
Almost all patients now are having that done at diagnosis. In regards to how frequently, it depends on a lot of factors. One of the biggest ones would be what’s the underlying health of the patient? So, would there be a utility in knowing are things changing? One of the reasons why you would want to know that, for instance, would be maybe their disease is bad enough at this time to say okay, a transplant is warranted, but you’re going to follow the patient closely
And if there’s new mutational changes or there are other signs or symptoms, then you might consider transplant at a later time. So when those patients are candidates for stem cell transplant, then I think one could argue that more frequent monitoring would be warranted. And so I might monitor those patients every six months to a year with mutational profiles.
I do think it should be done if there’s a change in symptomatology; if it looks like the disease is changing. So let’s say for instance you have an ET patient who’s been doing well on treatment for a long period of time, but they come in and they have low blood count now. And for the first time, they maybe need a red cell transfusion or maybe even a platelet transfusion. You’ve decreased their hydrea doses and their spleen has started to increase. You see immature cells in their blood smear. All of these are signs that maybe they’re going into myelofibrosis.
So if that were happening, that would be another reason that I would say okay, maybe we should do this mutational testing. So, I think it’s hard to be definitive; I think it’s an individual decision made after a consultation with the patient. And I think there’s a lack of data that we have to address your question, and that’s why you’re going to hear a lot of different opinions about when they should be done.
Absolutely. And James, I just want to go back to you for a few moments. Have you had genetic testing?
I think we all had it just to be sure about the Philadelphia chromosome. And I’m JAK2 positive, but other than that, no. I would like to interject sometimes the conversation has been once we find the right treatment; you’re going to stay on it. But if you get around a lot of patients, you’ll find that this drug works great for me for three years and now, for whatever reason I’m transforming; it isn’t working. Maybe I’m not transforming but it doesn’t work. But that’s the only thing I’ve had done.
Clinical trials and CALR and MPL I’m not sure right now what I’d change about my treatment. I haven’t gotten excited about that yet. But I’m aware of them through the conferences and through the Listserv.
Very, very interesting. You’re very connected and I know that when you and I talked before and we got to know each other, that you are very connected to what is out there and still kind of figuring out what do I need; things are going well. But James, you brought up a very good point. I’d like to ask Dr. Snyder; resistance. We hear the word so often, but could you talk to our viewers a little bit about what is drug resistance and what happens at that point?
Usually if you’re talking about resistance, say to hydroxyurea, a patient with P vera resistant to ruxolitinib, it usually implies – often implies that there is something new that’s occurred within those abnormal cells. We were talking about mutations, and that’s probably the main mechanism for the development of resistance; that a patient had a certain profile, let’s say they had the JAK2 mutation but no other secondary mutations.
Sometimes another mutation will develop in the course of the disease, and now even though for example with ruxolitinib, you may be inhibiting the JAK2 pathway pretty effectively; if a mutation has occurred that activates another pathway inside the cell, it may be able to bypass that blockade that the ruxolitinib was establishing and now the patient clinically becomes resistant. So it’s a time to wonder what’s happening at the molecular level and should we be looking at that.
If this fits into resistance and the whole issue, and we heard earlier from Dr. Scott talking about stem cell transplantation and I know that’s something that’s your area of focus. When you see resistance happening and you’re not finding another therapy that’s working, is that when stem cell transplantation is a viable option?
That’s a very good question, and not an easy one to answer.
I’m on a roll!
That’s the biggest question, really; well there are two. Who is the right candidate for stem cell translation, and when; when is the right time? We don’t want to compromise or jeopardize good quality of life that a patient may be experiencing with their current situation.
Stem cell transplantation, yes on the one hand it is a curative treatment potentially; that’s the goal of therapy with stem cell transplantation. But on the other hand, it’s a high risk approach as well, and there are risks of early death after transplant and if not death, then significant morbidity of complications that may affect the quality of life. So we certainly don’t want to rush into that approach. That’s the nuance of when is that right time.
I’ll just step back for a minute. We haven’t talked about DIPS or DIPS Plus, which I’m sure people are familiar with. That’s the Dynamic International Prognostic Scoring System for myelofibrosis that stratifies patients into low, intermediate one, intermediate two, and high risk. It helps to predict expected survival or average survival for a large group of patients with that category.
Generally speaking, once you get to intermediate two, the average predicted survival is under five years. That is to me sort of the minimum criteria to say we should be thinking about a transplant. But it’s not sufficient, because many people may be in intermediate two or even high risk and still have good quality of life. So I look for additional factors. One would be that a patient starts increasingly requiring red cell transfusion because of severe anemia; that’s one trigger. Because that would indicate that survival may be shorter.
The other is to look at the blasts in the blood. Patients may have none, or they may have a low number, say 1 to 3 or 4 percent; that hovers in that range. And then over time, something happens and now it’s 8 to 10 or 8 to 12 percent. Again, it may be one of those mutations that’s come along.
That gives you a sense that the patient is on the way towards transformation, so that’s another trigger to say this is the time to think about a transplant.
So definitely not a decision that is taken lightly; it is sort of a last sort of therapy, so to speak, a strategy to take because of the serious effects it could have on the quality of life, if I understand you correctly?
Again, in a sense it is. I like to say that I don’t like to take patients too early, nor too late to transplant. Because we want patients who are potentially going to benefit from it to have that chance. So too early means that a patient is doing well in their current therapy, they have a good quality of life, they’re doing the things that they need to do, that they want to do; we don’t want to interfere. Too late, that’s a relevant term because it’s hard to say that it’s ever absolutely too late.
But someone who’s transformed to leukemia, that’s a much more difficult situation. It’s not that we can’t transplant a patient in that situation; you need to go through treatments first to get the leukemia back into the more chronic stage. It complicates the whole picture; outcomes are not quite as good.
The other besides leukemia is the general organ function of patients as they get older and they have other issues. Their heart function, their kidneys, their liver, their lungs; those need to be in pretty good shape to be able to withstand the impact of a transplant.
So it’s a very intricate decision making process and highly specific, is what I hear you’re saying.
It is. I’d just like to get back a minute to what we’ve been talking about mutations.
As we’re learning more about what secondary mutations can be found and what their clinical impact is, they’re being incorporated into prognostic scoring systems so not just DIPSS, but there are things like MIPSS, molecular scoring.
So, incorporating those data along with the clinical parameters. We’re not ready yet, but there may be a time where we can define a patient’s risk through the genetic profile and allow us to say okay, this patient, even though clinically they’re doing well, we know that their risk for not doing well in the short term is X or it’s a much shorter timeframe, and we better not wait – or it would be better not to wait – to move to transplant since we had said that this patient is a candidate and they have a donor.
So we’re not going to wait and risk the chance that they would lose the benefit. We’re not there yet, but I think that’s the direction we’re hoping to head to in the coming years.
That’s great to hear about where we’re going with this; what we can expect in the coming years. It sounds like it’s going to get highly specific and very useful. Now I’d like to take the time to talk about some clinical trials. Dr. Scott, I’d like to have you start off with us. What’s new and promising? If you could talk about a few clinical trials that maybe are going on at SCCA, or that you’d like to share with us and then Dr. Snyder, we’ll go back to you and you can give us your feedback. So Dr. Scott, can you lead us into that subject?
Sure. We have a trial with a drug called imetelstat for patients with myelofibrosis. The accrual is currently on hold. A single center phase II result was published in the New England Journal of Medicine showing there were some patients who were able to retain a remission] of their myelofibrosis with treatment with imetelstat.
This includes both molecular remission and morphologic remission. Molecular remission would mean that their abnormal mutations went away and it responded, and morphologic remission would mean that visually the fibrosis had improved significantly. The phase II trial is currently on hold and they’re evaluating data. I’m helpful that the drug will continue to be explored in clinical settings. It does have a novel mechanism of action; it’s what’s called a telomerase inhibitor.
As I said, the drug is known as imetelstat. There are many centers that were participating in that phase II study. We just opened a trial with pactritinib. Pactritinib is also a JAK inhibitor, and actually I think it’s probably better to call these drugs JAK-STAT pathway inhibitors, because not all of them actually work directly on the JAK receptor, so I think that’s important to know.
These basically inhibit the JAK-STAT signally cascade. This drug, pactritinib, is in clinical testing. It is not yet FDA approved. It’s somewhat similar to ruxolitinib but it does appear to cause less cytopenias, so less toxicities with lowering of the blood count. It could be potentially useful in patients with low platelets. That’s one of the chief toxicities that can be seen with ruxolitinib are Jakafi is lowering of the platelet counts.
So, I’m hopefully that this drug will be approved in the near future. It was put on hold for the FDA for a brief period of time, but as I said the drug is now being studied again in a phase II trial, looking at different dosings. There are many centers participating in that study.
And then we also have a transplant study that’s looking at giving JAK inhibitors before transplant in an effort to improve the overall condition of patients before they go into transplant.
This is specifically for myelofibrosis patients. Patients with myelofibrosis can have a higher treatment-related mortality with transplantation because of other things that are going on with their body like malnutrition, the fact that they have a very big spleen, and other factors such as organ involvement with fibrosis can lead to a higher treatment-related mortality. They also have a slightly higher risk of graft failure in comparison to patients with other types of myeloid malignancies.
So, we’re hopeful that giving a JAK inhibitor before transplant can help improve the post transplant outcomes. So those are the three major trials that we currently have open. Of course there are other centers with really exciting drugs in development, as well.
Wow, that sounds very exciting. I know that I can say just hearing that there’s such a focus with MPNs and these trials.
And Dr. Snyder, what is going on in your neck of the woods at City of Hope and other trials that you’d like to tell us about?
Yes, we have a number of trials. We have the pacritinib and the imetelstat trial as well. We have two other trials that are for patients who have failed or progressed on ruxolitinib that have totally different mechanisms of action sort of outside of the pathways we’re talking about. One is called SL401, Stem Line 401. It’s an interesting sort of an immuno toxin; it’s a dual functional molecule that has an IL3, interleukin 3 portion that’s linked to a diphtheria toxin. It’s somewhat like a Trojan horse type of thing.
The cells in myelofibrosis and other hematological malignancies have an interleukin 3 receptor on their surface, and this IL3 molecule will bind to that interleukin receptor. That complex is taken inside the cells and then the diphtheria toxin is released and is able to kill the cell from the inside. So that’s one mechanism.
There’s another approach; there’s a molecule called CD47 which has been referred to as the “don’t eat me” signal. So, macrophages which are big cells in the body and in the blood and tissues, their name means big eaters. They like to eat foreign cells, tumor cells, bacteria, etc.
But some of the tumor cells or the malignancies become very clever and they have this protein called CD47 on their surface that sends a signal to the macrophage: don’t eat me, stay away and helps the cells to survive. So there is an antibody against the CD47 that binds to the CD47 and interrupts that pathway and then allows the macrophages to do their jobs, which is to eat these abnormal cells.
So that’s another approach that’s being tested not just in myelofibrosis but in other conditions as well. There is some data, sort of preclinical, that this approach may actually reverse fibrosis in some models, so it’s kind of intriguing particularly for patients with myelofibrosis.
The thing I will mention, we know that ruxolitinib is the only FDA approved drug so far; there have been several others unfortunately that have gotten just so far and then because of toxicities have been taken off of the table. But to me, I think another approach is combination therapy that is taking ruxolitinib as the base and then combining it with the second drug that has a totally different mechanism of action, and the two of them then perhaps can synergize and kill off the cells.
Those are trials, a quite a few of them going on around the country and I think those have a lot of promise.
And when you mention combination therapy, you both have mentioned it; are we looking at more of a personalized medicine? What’s your feeling on that, Dr. Snyder? Is it at that point we’re getting more personalized and we’re looking at that one person and saying this is going to work more specifically for you?
I think that’s a very good point, and I think as we learn more about mechanisms of action of some of these drugs and we talk about targeted therapy, it is something that can be very individualized potentially.
We talked about the genetic profile of what mutation someone might have. And so there may be a second drug beyond ruxolitinib that targets one of these secondary mutations that a patient might have. And so for that person with that particular combination of mutations, ruxolitinib plus this second targeted therapy may be just the right thing for them.
Even a drug like imetelstat, at least on data based on small numbers from Dr. Tefferi’s work suggested that there may be a mutational profile that defines the best responder type of patient, and conversely, patients who are unlikely to respond at all to that drug. That would be terrific to be able to say okay, don’t waste your time with this drug for this patient, but go in this direction because this is much more likely to be effective.
It could be life saving; it could get to the result much quicker than going through another therapy that just is not going to do it.
Very interesting. So, quick question for you James, before we move one. We’ve talked about a little bit about clinical trials. James, have you considered a clinical trial? Or you’ve been stable; would you consider one in the future if your condition changed?
Very definitely. But you know one thing we haven’t touched on and what drives the doctors crazy, probably, is the psychology of the diagnosis. We as patients quite often tend to think if I just took thing X or had therapy Y, I would be okay. And as these doctors know, it’s not that simple. But yeah, if I thought I would benefit from it and I needed to, of course.
You bring up an excellence point, James, because it is the psychology behind really how we… you’ve been doing this for 23 years and you obviously have educated yourself which helps you to understand what’s going on, which balances everything out. I know that I, as I mentioned, I’m in some support groups and I see people doing combination therapy. And it’s the old adage: he’s doing two things and I’m doing one, and I’m sure doctors don’t want to hear that.
There are other patients; the last thing they want to know is anything about the technical side. Just: I’ll go to the doctor and the doctor says this, and I do that.
There is, indeed.
I think even I’m on one extreme and they’re on the other.
Definitely. We have a little bit of time, and Dr. Scott, I’d like to go to you.
We have a question from Pauline, and she asks: is there any way to determine declining blood counts such as anemia and thrombocytopenias are due to drug side effects or the disease process? And she goes on to say: my husband has been on Jakafi for just over a year, and these declining cell counts began a couple of months ago. So let me know if you need to repeat that. Could you comment?
No, I’ve got it. There are things that are helpful to distinguish between drug toxicity and to these progressions, and one is timing. The cytopenias that are experienced with ruxolitinib, as long as the dose has remained the same are usually early side effects. So, most of the cytopenias are during the first eight weeks of therapy. So if you see early cytopenias, it’s more likely to be a drug effect. If you see later cytopenias, it makes you more concerned about disease progression. And to know definitively of course, you could repeat a marrow aspirate or a biopsy and that can be helpful.
And then other co-associated symptoms or size like increasing spleen size, or return of puritis can all be signs that the ruxolitinib is no longer working. But as I said, the side effects of drug-related are usually early events within the first eight weeks when treated with ruxolitinib.
Great. I think that’s going to be some good feedback for Pauline and some talking points that she can bring back to her specialist. We are coming to a close, and what I’d like to do now is ask each of our panelists just for some final thoughts or comments. You know, I’m feeling very optimistic from this discussion this evening to know that there’s just constant thought on these rare diseases, and there are clinical trials and research. But Dr. Snyder, let me start with you and if you could just give us some thoughts you’d like to share with us that you think would be meaningful?
Sure. These are obviously difficult diseases because they’re hard to cure. But I will focus first on the role of stem cell transplantation as the only current only curative approach. We are trying to improve both the efficacy and the safety of that approach, and Dr. Scott mentioned studying the role of JAK2 inhibitors in the peritransplant time, for example, as one. It turns out that ruxolitinib also is an effective drug to treat one of the main complications, which is graft versus host disease. We have a trial actually looking at it as a prophylactic way to prevent graft versus host disease.
So just to say that there’s a lot of work being done on that front to try to improve outcome for patients with the transplant approach. But of course we’d all love to have – we all think about CML, that was mentioned; the Philadelphia chromosome. The Gleevec story is kind of the model that we wish we could duplicate with many of the diseases that we treat, recognizing at the same time that it’s very unlikely.
Because in a way, patients and doctors were lucky with CML because it’s a very simple biology. And if you come up with a drug like Gleevec that targets really the definitive driver of that disease, you can have dramatic clinical benefit.
Not quite the case with the myeloproliferative neoplasms; more complicated. Ruxolitinib, we all hoped this is going to target the JAK-STAT pathway; it’s going to shut it down and restore normal hematopoiesis. It’s not quite that simple.
But we certainly have hope and optimism that with many of these trials that are going on, particularly as I said clinical trials with combination therapy, that that is going to get us closer to that point. I’m a transplanter but I would love to be put out of business because we have drugs or a drug that is so effective, transplant is just a thing of the past. Hopefully, one day that will be the case.
Wow, and that is very powerful. I will always remember those words; that’s really great. Dr. Scott, can you give us some final thoughts on just anything to let us know again what we should be looking for, what’s in the future, some optimism; whatever you feel is meaningful?
I think there is a lot of hope. When you compare what we know about myeloproliferative neoplasms now with what we knew about them six years ago, it is really remarkable. It was in 2005 that the first publications were published about JAK2, and we began our understanding of the underlying mechanisms of myeloproliferative neoplasms.
And over those 11 years there have been a lot of advances. So, I’m very encouraged by not only the clinical trial work that has been done, but also the basic science and the expansion of our understanding of these diseases. So when you compare what we have now with what we had ten years ago, it is really remarkable. I also do transplants but I do non transplant as well and I hope to be driven out of business. I would be okay with that.
That’s wonderful to hear; again very optimistic. James, you and I were chatting a little bit before our show started. James was commenting how even from 2014 to 2017, that there have been so many changes in progression and therapies. And James, I’ve got to say you’re like an MPN warrior.
You’ve been dealing with this for 23 years, you’ve been not only optimistic; you’ve been so resourceful, you are a born researcher. I would love to turn the stage over to you right now. And if you could give us some of your thoughts, some things you’d like us to know and help us feel more optimistic as we go forward.
Well, I’m very optimistic; I mean it’s just amazing compared to 1994. Actually, I was one of the data points in some of those 2005 studies. But there’s the MPN Research Foundation – let me throw in a plug for them, patients; they have funded some really specific studies. If you can’t go to conferences nearby or Scottsdale or New York – Dr. Silver runs one in New York; I know they’re in Seattle and all over now, get involved in a focus group. I drive to Dallas just to be around a focus group of those people. It’s tremendously empowering to talk to other people. Because your friends are like, you don’t really have a problem; you don’t look sick or anything, you know?
That is something that MPN patients hear quite a lot. But go ahead, James.
I’m just excited. When I have to get more knowledgeable and detailed about these things, I will but I’m not there yet. My goal is like the physicians here; I intend to die of something else. It didn’t get me the first time; I’m planning on no second time.
I think that is wonderful. You know, I would like to say that optimism is what is going to get us through this condition. I don’t tell too many people because I’m very optimistic, but I do agree with you James; I really connect well with people in focus groups. I drive sometimes about two hours each way into Los Angeles to see my specialist because that’s of value to me. If I ever could give advice, it would be make sure you’re connecting well with your specialist.
And that they are, like Dr. Scott and Dr. Snyder, very well versed in their field and in their clinical trials and things like that. So, wrapping up, a big thank you to our panel; I really believe that this webinar this evening gave us a great deal of information. Dr. Scott, Dr. Snyder, you both have very busy schedules so appreciate it. And James, you too took time out tonight so thank you all.
We have an upcoming webinar I’d just like to talk about really quickly on September 20th, and it’s what you can do to advance MPN research so I hope everyone will join us then. We will also be showing this video again and again. So thank you for our panel and thank you all for taking the time to watch Patient Power. Good night.
Is a clinical trial right for me or is it a gamble with my health? How will my loved one be affected? Do the risks outweigh the benefits? Watch as a panel of experts, including an oncologist, trial coordinator, and patient advocate as they debunk some of the myths around clinical trials. Listen to hear the patient voice and perspective for getting the best care-making decisions about clinical trials.
Watch to learn:
- What are common clinical trial myths?
- Why should patients participate?
- How can patients navigate the system?
- How can I or my care partner work with my medical team?