Tag Archive for: biomarkers

Expert Perspective | Key Advice for AML Patients

Expert Perspective | Key Advice for AML Patients from Patient Empowerment Network on Vimeo.

Facing an AML diagnosis can feel overwhelming. Dr. Omer Jamy shares tips for newly diagnosed AML patients, emphasizing the importance of a consultation with a specialist.

Dr. Omer Jamy is a Leukemia and Bone Marrow Transplant Physician and Assistant Professor at the University of Alabama at Birmingham. Learn more about Dr. Omer Jamy.

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What Are the Phases of AML Therapy


Transcript:

Katherine Banwell:

Dr. Jamy, for patients who have been diagnosed with AML, could you share three key pieces of advice for them. How can they be proactive in their care? 

Dr. Omer Jamy:

Sure. So, I feel like as a leukemia physician I would like to see, just to give you an example, I’d like to see all the leukemia patients in Alabama. But that’s not feasible, right? But what I would recommend to patients and caregivers is that wherever they are diagnosed, I do feel that they would benefit from a consultation with a leukemia physician at a tertiary care center or an academic center. And they would benefit due to various reasons, right? So, the first reason would be that as a leukemia physician my job is to just keep myself upgraded with leukemia care, leukemia management.  

So, one aspect of leukemia is therapeutics, right? So, drugs that are approved, easy to give. But the other aspect is understanding the biology of the disease, understanding how leukemia is going to behave. To get a better profile for AML for a patient. So, in a way saying that not all AML cases are the same. So, to be seen at a center would help the physician understand the unique cytogenetic or molecular profile of that patient’s AML which may be different from the next patient’s AML which could mean that the treatment algorithm for one person might be slightly different from the second person. So, I mean the academic and the people working at academic centers cannot survive without people working in the community, so it goes hand in hand. So, I feel like co-management of a patient with AML is extremely important. I feel like things will not get missed that way.  

I feel like the treatment plan, no matter where it is implemented, would really benefit the patient. It can be implemented closer to home as long as it’s been co-managed with someone closer to home as well as someone at the center where they have access to more information. What this would also help is get the person and the family plugged into a system where, let’s say if therapy wasn’t working, they’d have access to enroll on clinical trials down the line as well. Which unfortunately are only present at academic centers and not very widely available, especially for blood cancers. There may be trials for solid tumors easily conducted outside of academic centers, but unfortunately that’s not the case for blood cancers, specifically AML. So, the opportunity to enroll in clinical trials will also help.  

And then lastly, I feel like it’s our ability to offer bone marrow transplant to older patients has improved over the past 10 to 15 years.  

We’ve become better in identifying donors and in identifying patients, getting them ready for transplant that I feel that a person and the caregiver should inquire from their physician about the opportunity – oh, of No. 1 the need for transplant for the leukemia is because not all the AML patients may benefit from our transplant, but most of them do. And definitely anyone who relapses would benefit from a stem cell transplant.  

So, I feel like inquiring about that is very important because to get plugged in at a transplant center early on is important because you don’t want to waste time early on. You may not need the transplant, but just having the consultation and just having a preliminary donor search ongoing in the background is really helpful because when the time comes that a person needs the transplant, then you’ve already got some of that information ready, and you can proceed quickly. So, I feel like a few of those things might be helpful which I try to educate in the community as well and do outreach.  

Because I feel like it’s important to let people know that AML is an aggressive disease. Transplant is pretty intense, but we are now making it more and more tolerable for older patients. 

How Can You Thrive With AML? Advice for Navigating Care.

How Can You Thrive With AML? Advice for Navigating Care. from Patient Empowerment Network on Vimeo.

How can you thrive with AML? In this animated explainer video, an AML specialist and patient discuss how to make informed decisions about your care and live a full life with AML.

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Transcript:

Raquel: 

Hi, I’m Raquel. Nice to meet you! I am living with acute myeloid leukemia, or AML. When I was first diagnosed, my husband and I were very overwhelmed by a cancer diagnosis. But once I found the right care team and learned more about my disease and treatment options, I’ve been living a full life.   

Meet, Dr. Shaw – my doctor. 

Dr. Shaw: 

Hi! I’m Dr. Shaw, and I’m a hematologist specializing in the care of people with AML.   

AML is a cancer of the blood and bone marrow, and it is the most common acute leukemia in adults in the United States. Because this is an acute leukemia, it progresses quickly and should be treated immediately.   

There are typically two phases of therapy:  

  • Induction therapy is the first line of treatment and is meant to induce remission.  
  • The second phase is consolidation therapy which is meant to maintain the remission.  

As Raquel mentioned, with the right team and care plan, it is possible to live a full life and to thrive with AML. 

Raquel: 

It’s so true. Navigating my care has been much easier, because I partner with my healthcare team – it makes me feel involved and confident in decisions. 

Dr. Shaw: 

That’s right, Raquel. When considering treatment, it’s important to weigh all of your options.  

While your healthcare team is the expert when it comes to the clinical side of your disease, you, as the patient, are the expert on how treatment will impact YOU and your lifestyle.  

Raquel: 

And as someone who knows my needs well, my husband is another key member of my team.  He comes with me to appointments and takes notes during visits, and when it is time to make decisions about my care, we both feel well-informed about the options. 

So, Dr. Shaw – what factors should be considered when choosing an AML treatment? 

Dr. Shaw: 

Well, it’s important to note that everyone’s AML is different, so what may work for one person may not work for another. In general, we consider certain factors, such as: 

  • The patient’s age and overall health. 
  • Any pre-existing health issues. 
  • Test results, including any mutational testing results. 
  • Finally, and most importantly, the patient’s treatment goals and preference. 

Raquel: 

And I like to make informed decisions. So, when considering therapy, I also did some research on my own, and then discussed the information with my healthcare team. It helped my husband and me understand what we’d learned, and confirmed our decision. 

Dr. Shaw, what sort of questions should patients ask their doctor when considering a treatment plan? 

Dr. Shaw: 

Great question. When choosing therapy, patients should ask: 

  • How is the treatment administered, and how often will I need treatment? 
  • What are the potential side effects of the treatment? 
  • How will the effectiveness of the treatment be monitored? 
  • And, what are options if this treatment doesn’t work for me? 
  • Is there a clinical trial that might be right for me? 

Raquel: 

That’s great advice. Once you’ve begun treatment, it’s important to continue to share how you are feeling with your healthcare team – be sure to mention any side effects or symptoms you may be having. 

Dr. Shaw: 

That’s right, Raquel. If you speak up about what’s bothering you, we can usually find a way to manage the issue. 

It’s also important point to tell your doctor if you’ve missed a dose of your medication. Many of the newer AML therapies are self-administered, and it’s important to let us know so we can adjust the plan if necessary. 

So, Raquel, can you share advice for thriving with AML?  

Raquel: 

  • First, understand and participate in treatment decisions. Be sure to educate yourself about AML and share your personal preferences when choosing therapy. 
  • Then, communicate regularly with your healthcare team – don’t wait to share information only when you have an appointment.  
  • And, utilize your whole team – nurses, nurse practitioners, and others, are all there to help you. 
  • Use your patient portal. You can view lab work and test results, or even use the messaging feature to communicate with your team. 
  • Bring a friend or loved one to appointments and always write down any questions or concerns in advance. 

Dr. Shaw: 

And, most importantly, remember you are at the center of your care. Advocate for yourself! 

To learn more, visit powerfulpatients.org/AML to access a library of tools. Thanks for joining us! 

How Do Biomarker Test Results Impact a Gastric Cancer Treatment Plan?

How Do Biomarker Test Results Impact a Gastric Cancer Treatment Plan? from Patient Empowerment Network on Vimeo.

What impact do biomarker test results have on gastric cancer care? Expert Dr. Matthew Strickland explains how the identification of biomarkers affect treatment choices and why patients should insist on this essential testing. 

Dr. Matthew Strickland is a medical oncologist at Massachusetts General Hospital. Learn more about Dr. Strickland.

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Transcript:

Katherine Banwell:

Dr. Strickland, how do biomarker test results impact gastric cancer prognosis?  

Dr. Matthew Strickland:

So, biomarkers will directly guide our treatment decisions in how we can assemble the best treatment plan for our patient as an individual. That will have direct ramifications for how well and for how long that therapy can work for.  

So, I would say that there’s a direct correlation between the biomarker analysis to prognosis.  

Katherine Banwell:

Dr. Strickland, how do biomarker test results impact gastric cancer treatment options?  

Dr. Matthew Strickland:

So, for example, depending on the stage…if a patient has a stage IV cancer, PD-L1 expression will guide our treatment decision whether to include immunotherapy typically with a chemotherapy background or not. To say that a different way, if the expression is very low or absent, we know that patient likely will not benefit from immunotherapy and could actually be harmed, because there is some toxicity that comes with these treatments. That’s one example. But similarly for HER2+ patients, we’ll similarly assemble a treatment regimen with a targeted therapy that is included.  

That certainly guides treatment options, specifically based on a HER2-positive result or negative. The next biomarker I want everyone to know about is called PD-L1. That stands for programmed death ligand 1. This is also a protein that’s expressed on the surface of cancer cells.  

That usually leads to a better outcome than for patients that we can’t include a targeted therapy and left relying on chemotherapy only.  

Katherine Banwell:

Dr. Strickland, what questions should patients ask their healthcare team about testing and test results?  

Dr. Matthew Strickland:

Because biomarker status is so critical for treatment decisions and leading to outcomes and prognosis, I would encourage patients to ask their provider if all standard biomarkers have been obtained at the time of their diagnosis. Sometimes that answer is no, but they’re working on it. That’s okay. But I would highly encourage patients to just ensure that standard biomarkers are being tested for, that they will directly guide the treatment recommendations.  

Katherine Banwell:

Dr. Strickland, is there developing research or treatment news that gastric cancer patients should know about?  

Dr. Matthew Strickland:

I think it’s a very exciting time for the treatment of gastric cancer. Now, we still have a lot of work to do. I don’t want to minimize. This is still a tough and can be an aggressive cancer. It’s no time to let up.   

That being said, if we use immunotherapy as an example alone, there’s been a flurry of new approvals for standard of care in the last three to four years. Our understanding is only increasing of how to select the right patients that will benefit as well as how to avoid some of the toxicities. Beyond immunotherapy, there are new and emerging targets that we can design targeted therapy for.  

We don’t yet have mainstream approvals for targets like Claudin 18.2. But this is a very exciting new target that I think will lead to an approval in the short future.  

How Is Gastric Cancer Biomarker Testing Conducted?

How Is Gastric Cancer Biomarker Testing Conducted? from Patient Empowerment Network on Vimeo.

Biomarker testing is essential for gastric cancer patients, but how is it conducted? Expert Dr. Matthew Strickland explains the methods of biomarker testing and the common biomarkers associated with gastric cancer.

Dr. Matthew Strickland is a medical oncologist at Massachusetts General Hospital. Learn more about Dr. Strickland.

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Transcript:

Katherine Banwell:

So, how is biomarker testing conducted? Is it via a blood test?  

Dr. Matthew Strickland:

This is also an excellent question. Biomarkers can often be tested in different ways. Most of the biomarkers that I’ve outlined start by being tested via cell surface expression of those proteins. Basically, that translates to once the biopsy of the tumor is taken out and is now in the pathology lab, a pathologist can apply different stains to identify these proteins and biomarkers.  

Then, they can assess, in other words, quantify the level of expression. This method is called immunohistochemistry. I would say it’s a fair statement to think this is a first pass method of detecting biomarkers.  

But it’s not the only one. Beyond that…there’s, for example, HER2 can sometimes reflex to assessing the copy number of the gene. So, we’re no longer talking at the protein level. Right now, we’re talking about using a method…the acronym is FISH, which stands for fluorescence in situ hybridization. This is a method to quantify the number of copies of the gene.  

If the cancer has indeed overexpressed HER2 to gain a growth advantage, then often we’ll see a very significantly high copy number. Then, to address your question regarding biomarkers detected in the blood, this is also a new area, relatively new. We know that there are fairly effective tools to test for circulating tumor DNA.   

Backing up for a moment, cancer cells can – let me rephrase. Cancer cells will to some degree shed their DNA into the bloodstream. We are able to detect that unique DNA to some degree. So, these tools, which are generally called circulating tumor DNA assays, there are different companies. The names of their products can be different. But they’re becoming increasingly effective at detecting tumor DNA in the blood.  

So, there are several approvals for these tools. But this can get a little bit tricky. Because the tools are so new, they’re not yet integrated into our standard management. So, perhaps, at larger cancer centers you might see providers utilizing these tools, but it might not be offered at every location.  

Essential Testing Following a Gastric Cancer Diagnosis

Essential Testing Following a Gastric Cancer Diagnosis from Patient Empowerment Network on Vimeo.

What testing should newly diagnosed gastric cancer patients undergo? Expert Dr. Matthew Strickland discusses what is analyzed in biomarker testing and how immunotherapy works against cancer.

Dr. Matthew Strickland is a medical oncologist at Massachusetts General Hospital. Learn more about Dr. Strickland.

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How Do Biomarker Test Results Impact a Gastric Cancer Treatment Plan?

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Should Gastric Cancer Patients Consider a Second Opinion?

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Should Gastric Cancer Patients Be Treated Immediately?


Transcript:

Katherine Banwell:

Dr. Strickland, what biomarker testing is standard following a gastric cancer diagnosis?  

Dr. Matthew Strickland:

This is a very active area both for approved targets as well as from a research side of things. We’re trying to discover new biomarkers. I think it’s a critically important question. There are really three major biomarkers to help us make conventional treatment decisions. I’ll list them off first. Then, perhaps, I’ll break them down. The first is HER2. That’s H-E-R-2. Typically, folks have heard of this biomarker who are more in the cancer.  

But the truth is that the same molecular alteration happens at a relatively high frequency for gastric cancer. It’s a critically important biomarker because if we determine that the tumor is HER2-positive, what this tells us is that the cancer is thriving based on this protein in the signaling machinery downstream of this protein. The reason we like to know that is we can then target it as a vulnerability of that cancer.  

That certainly guides treatment options, specifically based on a HER2-positive result or negative. The next biomarker I want everyone to know about is called PD-L1. That stands for programmed death ligand 1. This is also a protein that’s expressed on the surface of cancer cells.  

What we’ve come to understand is that high expression of this protein will interact with immune cells in such a way that it tells immune cells to turn the dial down on their activity. From the cancer cell standpoint, this is a very clever mechanism. Because in normal circumstances, our immune system actually can detect cancer and eliminate it to some degree.  

However, when cancer cells choose, if you will, to overexpress this protein on their surface, it can act as a cloak. Suddenly, the immune system can no longer effectively detect and, of course, attack that cancer cell. This is critically important to know because if indeed a cancer cell is using this mechanism to survive, then we can also take advantage of this vulnerability. 

We can add various immunotherapy therapeutics to the treatment plan. The last biomarker of three that I think up front are very important to know about is called mismatch repair status. Mismatch repair proteins are important proteins that we have in all of our cells. Nature basically gave us these proteins to fix small mistakes in the DNA replication.  

That is to say when we’re growing and cells are dividing, DNA, which is the blueprint for our healthy cells, is copied. There’s a very low rate of mistakes, but there is a constant rate of mistakes. So, nature gave us what are called mismatch repair proteins that literally sit on the back of the enzymes that are doing the work.  

They can detect mistakes; they can snip out those mistakes. They can reinsert the right base pairs to fix the proper DNA code. Now, if these proteins are lost or their function is impaired, this can be advantageous to a cancer cell. The reason is mutations and mistakes will pile up, and they don’t get corrected. This can lead to certain growth advantages for the cancer.  

We know that gastric cancer at a relatively high frequency will utilize this mechanism to propagate itself. So, again, by knowing that the cancer is relying on this mechanism, we can directly take advantage of this as a vulnerability. We can improve the outcomes for the patients through their treatment. 

Emerging Treatments for Head and Neck Cancer

Emerging Treatments for Head and Neck Cancer from Patient Empowerment Network on Vimeo.

Expert Dr. Ari Rosenberg discusses the importance of head and neck cancer clinical trials and shares an update about emerging research in treatment strategies and tumor DNA testing.

Dr. Ari Rosenberg is a medical oncologist and assistant professor of medicine at The University of Chicago Medicine. Learn more about Dr. Rosenberg.

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Transcript:

Katherine:

Well, that leads us to my next question, which is where do clinical trials fit in? 

Dr. Rosenberg:

So, clinical trials are really important for head and neck cancer because as much as we have tools to treat the disease, the tools that we have are suboptimal.  

They’re what we have, they’re what we use, and they can be quite successful in many cases, however, we can do better. We need better treatments for head and neck cancer. So, broadly, the clinical trials can actually be across multiple different treatment settings, whether earlier stage disease, or later stage disease. And the goal of the clinical trials are often to develop better treatments. What can that mean? Treatments that work better against the cancer, so help patients live longer with better quality of life. 

Sometimes clinical trials evaluate strategies to reduce the toxicity, or the side effects associated with treatment, so many trials are trying to evaluate strategies to reduce some of those kinds of side effects with the treatment. And then many trials are also trying to use, for example, new biomarkers, or new tests, which can help sometimes predict which is the right treatment for the right patient.  

One patient may need a more aggressive treatment, one may need a less intensive treatment. So, at our center, for example, we have clinical trials that, depending on the particular circumstance for those patients, that are trying to take what we have as the current standard, and build on that, to either improve survival and outcomes for patients, or reduce side effects, or both in order to optimize patient outcomes.  

Many of our clinical trials incorporate new immune therapies. So, immune therapy treatments are strategies that harness the body’s immune system to attack cancer, and we’re trying to identify new ways to do that. Some of our clinical trials are focused on trying to make the radiation, or the chemotherapy and the radiation, a bit more precise, and focused on the specific tumor. And some are focused on identifying what the best treatment would be for one particular person’s tumor, because we know that actually it’s many different diseases.  

And so, we want to really figure out what the optimized treatment is for giving patients that increases survival while reducing treatment-related toxicity. Again, that’s really the overarching goal of what we’re trying to achieve with clinical trials for head and neck cancer.  

Katherine:

Yeah. What about emerging approaches for treating head and neck cancer? Is there research going on that patients should know about?  

Dr. Rosenberg:

Yeah, definitely. So, many new drugs are being developed for head and neck cancer with many different treatment strategies. I would say given the success of immune therapy recently for head and neck cancer, and other cancer types as well, many are trying to build on that, and identify better immune therapies that work better against cancer therapies. Some are targeted therapies, so developing new drugs that maybe target a specific mutation, or a specific change in a particular patient’s tumor that would be appropriate. 

And the other thing that is being developed is strategies that incorporate, for example, blood tests that can sometimes measure tumor DNA in blood in a non-invasive fashion that can reveal all sorts of specific information about that particular patient’s tumor, how they’re responding to therapy, and can hopefully help optimize and personalize therapy. So those are some of the more emerging approaches that are being developed in clinical trials for head and neck cancer. 

Expert Advice | Shining a Light on Equitable AML Care

Expert Advice | Shining a Light on Equitable AML Care from Patient Empowerment Network on Vimeo.

While treatment options are improving, there are still many factors impacting equitable care for AML patients. Dr. Ann-Kathrin Eisfeld shares advice for improving research and clinical trials for underserved AML populations.

Dr. Ann-Kathrin Eisfeld is Director of the Clara D. Bloomfield Center for Leukemia Outcomes Research at The Ohio State University and a member of the Leukemia Research Program at the OSUCCC – James. Learn more about Dr. Eisfeld.

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Transcript:

Katherine Banwell:

Dr. Eisfeld, we’ve covered a lot of information related to AML care. As a researcher, what other topics are currently top of mind for you in the field of AML? What are you passionate about? 

Dr. Eisfeld:

Again, so many parts. I think there are probably three main things that I’d like to name. And I think about it as a little bit outside the box. Most of what we know about AML, we have become so much better. It’s because we have been studying patients who were treated over the past decades on clinical trials and very often here in the U.S. or in Europe.  

But all clinical trials have a bias in that most of them have been done A) on patients who are younger than the age of 60. And B) fewer patients of other races and ethnicities included. And had patients not included that have AML, for example, not only in the bone marrow but on extramedullary sites – how we call it – up to 10 percent of their patients. And also, very often have not been done on very old patients where the AML is very common. So, all the patients – patients from other race, ethnicities, or underrepresented minorities, and patients who present with extramedullary disease are currently in my – underserved.  

And these are exciting areas and opportunities of research and of active clinical practice. Because those are the patients we need to include if it’s possible now to include them in clinical trials. 

If there are no trials available, then make sure any other additional molecular testing it done to understand them better and to advance our disease knowledge that we make sure that we can give the best possible care.  

I think that the most important part is to get the molecular testing, and to enroll into clinical trials, and then to very often biobanking 

Why am I saying that is because our knowledge AML comes from patients who donated some tissue so that we could learn – researchers decades ago could learn about the genes. We know that leukemias differ so much in between patients.  

So, I am worried that we are yet missing out on potentially important genes that need to be discovered and where we could develop docs for. This will only be possible with these additional testing. 

 The second part is to really consider going to larger treatment and larger treatment cancer center. And there are support systems in case that can help in here.  

And the third part is to get involved even as early as possible even if you’re not personally affected, with Be The Match – with bone marrow transplant because there’s a paucity of donors, of people of color that makes it harder for these patients to get a potentially curative treatment in here.  

We have other options now in bone marrow transplant where one can use only half-matching donors and or other availabilities. But again, that doesn’t outweigh that the bone marrow and donor registry that we need to get better at.  

And I can – there are just so many factors – such a high degree of structural racism that affects people from every corner. And I think we as physicians, as society, and everybody need to acknowledge that. And we have to make sure that we get better to, again, give every patient the best care and keep the patient in mind and see what’s right for them at the right moment.    

Katherine Banwell:

Where can patients or people who are interested find out about being a donor? 

Dr. Eisfeld:

There is the website called “Be the Match” that one can put in. This is probably the best way to get first information.  

And usually, at all the cancer sites. And sometimes, there is information at lab donation places, universities, either or the American Red Cross. Usually those places have information laid out there as well. 

Emerging AML Treatment Classes Showing Promise

Emerging AML Treatment Classes Showing Promise from Patient Empowerment Network on Vimeo.

What therapies are in development for acute myeloid leukemia (AML)? Dr. Ann-Kathrin Eisfeld discusses the latest research for AML treatment, including menin inhibitors and CAR T-cell therapy.

Dr. Ann-Kathrin Eisfeld is Director of the Clara D. Bloomfield Center for Leukemia Outcomes Research at The Ohio State University and a member of the Leukemia Research Program at the OSUCCC – James. Learn more about Dr. Eisfeld.

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Transcript:

Katherine Banwell:

Are there therapies in development that are showing promise for patients with AML? 

Dr. Eisfeld:

There are so many of those. It’s hard to count. And this makes me very happy. There are exciting and again, targeted drugs.  

Once drug class is called menin inhibitors, which we – which were just published that show high promise.  

And again, very difficult to treat several groups of patients who harbor chromosome changes in MLL genes in here. So, that is a very exciting option.  

And there’s very exciting treatments with respect to what you call antibodies – monoclonal antibodies that attacks the surface proteins that are being checked regularly. And one of those, for example, is called magrolimab. And that has even promise in these high-risk leukemias or adverse risk leukemias.  

And then we are not there yet, but I’m sure we will be in the not too near future. There are also multiple trials that are looking at what we call CAR-T cells. But patients might have heard about for lymphomas or acute lymphoblastic leukemias. AML is a little more tricky with respect to those. 

But we’ve seen pre-clinical studies that look really exciting. And I think it’s just going to be just a little more fine-tuning to make those easier, available, and more targeted for AML patients. And I’m very much looking forward to seeing those come more onto the market.     

Katherine Banwell:

You mentioned the new menin inhibitors. Who are they right for?  

Dr. Eisfeld:

We try to find out more, but definitely for patients that have been shown to be beneficial for patients who have chromosomal and rearrangements of the MLL gene or KMT2A gene. And there’s also good data on patients who have NPM1 mutations.  

Even though we know – and these are mutations who harbor this kind of genetic change – have now a plethora, which is a great, of treatment options. 

Because we know even conventional chemotherapy has been working decently well in them. We know that venetoclax also is supposed to work very well in them. But again, the data on the menin inhibitor with respect to NPM1 mutations is very exciting. 

AML Treatment Approaches | Factors That Impact Options

AML Treatment Approaches | Factors That Impact Options from Patient Empowerment Network on Vimeo.

What factors are considered when choosing an AML treatment approach? Dr. Ann-Kathrin Eisfeld explains how shared decision-making comes into play when deciding on a therapy and reviews the options available to treat AML.

Dr. Ann-Kathrin Eisfeld is Director of the Clara D. Bloomfield Center for Leukemia Outcomes Research at The Ohio State University and a member of the Leukemia Research Program at the OSUCCC – James. Learn more about Dr. Eisfeld.

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Transcript:

Katherine Banwell:

With all the new tools that are available, what other factors do you consider when working with an AML patient to choose a treatment approach for them?  

Dr. Eisfeld:

The most important aspects are what we call – and this is – I’m glad that you bring this question up because I feel you have to think of – and that was what we’ve been talking about – called disease-associated factors. This is everything in the leukemic cell. They – how does a leukemia looks like? How does the blast look like? What changes are there?  

That’s the biggest part of what I would call patient-associated factors: the patient age, the patient performance status, actually the patient. In every – because I think, sometimes, we forget about it. But we just look at all the molecular testing.  

But even if – for example, there would be a patient with a very good risk leukemia, where I think, “Oh, this leukemia should respond very well to an intensive chemotherapy.” 

If the patient cannot tolerate chemotherapy or – and I see it more often than I would wish for patients who are young who have a great performance status, but they just cannot – they – their family reasons. Small children sometimes – they just cannot be away for so long. This all comes into consideration. So, it’s really important because we all work together as a team. And the right treatment for the leukemia might not be the right treatment for the patient.  

And for most cases, however, I think, it will only work if one stands with a whole heart with both physicians, and patients, and family. Because it’s a long journey behind the care that’s being given. And so, this is a joint decision-making, and there are different options that can be done. Of course, I would not advise something where I would think there are no chances of success.  

And so, this has to be an open discussion. But this is – it’s very often a very tough treatment to communicate that and see what are the goals of each patient? That will be most important for treatment and decision-making.     

Katherine Banwell:

What types of AML treatment classes are currently available?  

Dr. Eisfeld:

This is a very good question. The most classic treatment class is intensive chemotherapy. This is just because people might have heard the names. It is called 3 + 7 or 7 + 3, which refers to one weeklong impatient chemotherapy treatment. But you get one chemotherapy for seven days. And the first three days, you get a second treatment as well.  

That’s why it’s called three in seven in here, but it’s a total of seven days. So, we have intensive chemotherapy. And there are different flavors of it. But this is usually the backbone. The second class is what I would call a targeted inhibitor. And here we can look at two different aspects. We have targeted inhibitors for a specific DNA mutation that are found. And specifically, one are called IDH or FLT3 mutations.  

And these are pill forms that I usually by now combined with a third drop class which is called hypomethylating agents. And I will go through in a moment.  

But these are pills that really only work in patients and carry that genetic change. They have very, very low toxicity and very high chances of working. So, that’s why this testing is so important to see if one is one of the 15 percent of AML patients carrying an IDH mutation – 15 percent isn’t low. And a similar rate carries a FLT3 mutation.  

And then there is also going to target inhibitors. That is targeted because it is against what I would call a pathway. The gene that is commonly activated in acute leukemia – and this is called BCL-2 and the drug is called venetoclax (Venclexta).  

This is now stormed through the acute myeloid leukemia world in just a few years ago and has been approved as a front-line treatment option for several patients, especially for those who are older. And we know that even patients who respond usually favorably to chemotherapy, some of those also respond well to venetoclax the Bcl-2 inhibitor. The benefit is that this treatment in many cases if it works, can be done as an outpatient in here and has very often lower complications.  

It is actually has so good results that I – sometimes it seems too easy. So, we actually advise patients to still try to get – the first time they get the treatment, do it at a center where it’s done more commonly. Because it sometimes – don’t underestimated the power of a pill. And it’s still a very, very powerful drug. So, doing it in a controlled setting – because if cancer cells break down, they break down and can create all sorts of trouble.  

So, that is really something – for several leukemias, it can be concerning. And again, now the treatment group would be called hypomethylating agents. The names are azacitidine (Vidaza) and decitabine (Dacogen). And they act in a very different way. They try to change the epigenetics like methylation patterns. And often, if it is an untargeted way of the tumor cells and they can be used alone.  

Or very often by now in combination with the targeted inhibitors that I was just mentioning. These are infusions that can be done either over five, seven, or 10 days depending on the combination treatment. And for patients, as I mentioned before, that don’t respond well to many other options to those patients with a complex karyotype. This is, for example, a scenario where patients can just receive this as their only therapy.          

Katherine Banwell:

What about stem cell transplant? You didn’t mention that.   

Dr. Eisfeld:

Yes. That would be the next one. So, stem cell transplant always comes as an option, which I would call as a maintenance therapy. Again, two aspects. We have two different end goals.  

First is get rid of some leukemia. Second is to make sure it stays away. And as soon as the leukemia is in complete remission, depending on the performance status – the agent. Again, in multiple different things. It’s not an easy decision. 

At that time, there has to be a conversation. And that always involves a leukemia physician and a transplant physician very often. These are different providers that goes for the risks and benefits. Where the question is if I only continue to do chemotherapy – because it’s never only once. You would always have to repeat your chemotherapy. What is the likelihood that the leukemia comes back, and does it outweigh the risks that comes with the stem cell or bone marrow transplant that comes in here. But for many leukemias, especially for young patients and for patients with higher risks, this is the only chance of a cure. That is the most curative and only curative attempt for many leukemia attempts.  

Katherine Banwell:

Where do clinical trials fit into the treatment plan? 

Dr. Eisfeld:

That is the absolute backbone. We always have to think about that. 

Everything – all the treatment options that I mentioned – have been clinical trials, just very, very short time – very few years ago. So, every patient that comes to a leukemia or a cancer center, clinical trials will be discussed if they’re available. Because they will provide a special opportunity to have even more fine-tuned treatments – either newer agents. And I think what is very important to mention is that all clinical trials that are available would give the option of the best standard of care.  

And then the hope that a patient wouldn’t be getting any of the best standard of care options that are approved. The hope is that the new agent or added agent in many cases would even do better.  

It’s also important that there’s a lot of additional monitoring during the trial. I think it can be seen in two ways as two parts of a coin. In one way, it may be additional visits to the hospital or additional blood draws that are necessary to be sure that the medications are safe, and that researchers and conditions can learn about it. But on the other hand, it also gives you this extra bit of being looked after and really getting checked in and out, making sure that all organs are functioning that everything is just going fine. And many patients appreciate this a lot. And they have this pair of extra eyes on them all the time.  

Katherine Banwell:

Dr. Eisfeld, what therapies are available for AML patients who relapse or don’t respond to initial therapy? And is this treatment approach different from those who are newly diagnosed?  

Dr. Eisfeld:

Most of the time, the treatments available at relapse are the same available at the first diagnosis. Just because we know now that, for example, if you have a molecular marker that, for example, is available, it would act with also relatively high chance of relapse upset. However, at relapse, the most important thing I personally would do is consider a clinical trial even stronger than in the first mindset. 

 Because it means that the leukemia outsmarted current treatments very often. So, usually what we would be doing is see if there is a targeted inhibitor or a cell mutation FLT3 or IDH, which I would personally always prefer to go in MLL rearrangement now for the new menin inhibitors where one would go with the same option as if it would have been their diagnosis. But if not to really consider clinical trials is a strong urge. 

Katherine Banwell:

Should patients or should relapsed patients undergo genetic testing again? Is it necessary?  

Dr. Eisfeld:

Yes. At any time. Yes. Because we know that the leukemia changes. And you just can think about it in the way is that the cells that are surviving treatment, they’ve become smart. There was so much poison. There was so much treatment put on them. 

And the ones that survive might have a quiet additional chromosome change as additional gene changes. And even if a genetic change has not been present at time of diagnosis, the reason the cell has survived might have been that it has now one of these changes that came up on a later time during treatment or while the cell is hiding somewhere to come back. 

How Have Advances in Testing Impacted AML Care?

How Have Advances in Testing Impacted AML Care? from Patient Empowerment Network on Vimeo.

Recent testing advances have dramatically improved care for AML patients. Dr. Ann-Kathrin Eisfeld discusses these improvements and why every AML patient should undergo in-depth molecular testing before making a treatment choice.

Dr. Ann-Kathrin Eisfeld is Director of the Clara D. Bloomfield Center for Leukemia Outcomes Research at The Ohio State University and a member of the Leukemia Research Program at the OSUCCC – James. Learn more about Dr. Eisfeld.

See More From INSIST! AML

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Transcript:

Katherine Banwell:

Dr. Eisfeld, the landscape of AML has changed significantly in recent years. How have advances in testing improved patient care? 

Dr. Eisfeld:

It is a different world, Katherine, honestly. I mean, I started practicing in hematology in taking care of AML patients back in Germany actually in the year 2007. 

Back then, there was no other testing that was available. All we were guiding and all that we had available was morphology and cytogenetics 

And very often, it was very inaccurate. And we also only had two treatment kinds available. One was intensive chemotherapy, and one was something that was just a little bit better than best supportive care. So, many patients could not receive treatment. And the increase in knowledge that we have on a molecular level in AML really did two things at once.  On one, we understood we had a more finetuned understanding on which patients would respond. And the second thing is that this knowledge about the molecular landscape enabled us to have new treatments available that are sometimes in pill form that can target specific mutations in patients who carry these genetic changes.  

Katherine Banwell:

Should all AML patients undergo in-depth testing like biomarker testing or cytogenetics? 

Dr. Eisfeld:

Yes. Every patient should do that. It can make the difference between life and death. And it can make the difference between receiving – having a hospital stay of four weeks with intensive chemotherapy versus taking the pill at home. This is very rare that this is possible. But it is possible. And of course, you – one would not want to miss this chance if it would be possible.  

Katherine:

I’d like to get your thoughts on where we stand with progress in the field of AML. What would you like to leave the audience with? Are you hopeful? 

Dr. Eisfeld:

I am incredibly hopeful. I hope – when I started working in hematology, as I said at that time, it was just about when imatinib (Gleevec) came out. Which is this CML pill that really revolutionized care. And so, at that time, I would be – all patients on that bone marrow transplant service had chronic myeloid leukemia. And because they all had to undergo bone marrow transplant. Then Gleevec came, and today, there are no such patients who are see or very rarely that require such intensive care.  

So, I am very hopeful that in my practice time, which hopefully –and even earlier on – that there will be a time where we find targeted therapies for almost all patients.   

Low-Risk Versus High-Risk AML

Low-Risk Versus High-Risk AML from Patient Empowerment Network on Vimeo.

How is AML risk determined, and how does it affect treatment options? Dr. Ann-Kathrin Eisfeld defines low-risk and high-risk AML and explains how this classification may predict disease response to therapy.

Dr. Ann-Kathrin Eisfeld is Director of the Clara D. Bloomfield Center for Leukemia Outcomes Research at The Ohio State University and a member of the Leukemia Research Program at the OSUCCC – James. Learn more about Dr. Eisfeld.

See More From INSIST! AML

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AML Targeted Therapy: How Molecular Test Results Impact Treatment Options

Transcript:

Katherine Banwell:

Many cancer types are typically staged. But that’s not the case with AML. AML is often considered low risk or high risk. Is that right? 

Dr. Eisfeld:

Yes. And we – I think that’s very well how you put it. And we can even – they even add an intermediate risk by now to it. And I love this question because that’s what I like to study or what I’m studying here. The one important thing to keep in mind – and this is something even many hematologists don’t think about – 

– is that the risk assignment of acute leukemia, of AML if you think about it as low, or high, or intermediate risk is risk – or is actually better said not risk, but chances to respond to conventional chemotherapy. So, the way all this was defined is that if you have, for example, a multitude of chromosomal abnormalities – as you call it complex karyotypes – it would be considered adverse. This means your chances of responding to the standard of care in terms of chemotherapy are very, very low.  

And similarly, if you have other changes such as a NPM1 mutation, your chances are considered very high. And but – so, the risk assignment with the increase of treatments now changes. We still also – and when I look at that, I think about it in the same way. But in my mind, if I’m talking to a patient, I’m trying to make sure to say, this is considered an intermediate or adverse risk.  

But this means that I would not, at the first place, consider you for a standard chemotherapy but rather advise you to participate in a clinical trial or have an alternative care. The second implication especially for younger patients would be to – if you’re intermediate or adverse risk, that you would routinely be considered for bone marrow transplant or stem cell transplant.      

Katherine Banwell:

Okay. So, what does it mean to be high risk then? 

Dr. Eisfeld:

It means that your likelihood of going into remission – the standard of care is very low.  

This means – I mean, in very practical numbers, it might be as low as 20 or 30 percent. This meaning getting the leukemia into remission, there are very important differences. The first step at every time in the same high risk means if the patient receives the treatment, how high are the chances that we can get rid of the leukemia? 

The second question is how high are the chances once it’s gone that it stays away? Or how high are the chances of relapse? In adverse risk most cases, it’s both – a combination of those. The chances of going into complete remission are lower and the chances of it coming back are higher. So, we have to be very aggressive. This means that we have to consider alternative treatment options. And even if we are then lucky and achieve remission, that we might have to move to more intensive additional treatments such as a bone marrow transplant.    

Essential Testing | Optimizing AML Care With Personalized Medicine

Essential Testing | Optimizing AML Care With Personalized Medicine from Patient Empowerment Network on Vimeo.

Personalized acute myeloid leukemia (AML) care is becoming increasingly common, but how does it work? Dr. Ann-Kathrin Eisfeld defines personalized medicine and reviews the testing that should take place to help create an individualized treatment approach for patients.

Dr. Ann-Kathrin Eisfeld is Director of the Clara D. Bloomfield Center for Leukemia Outcomes Research at The Ohio State University and a member of the Leukemia Research Program at the OSUCCC – James. Learn more about Dr. Eisfeld.

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Transcript:

Katherine Banwell:

How would you define personalized medicine as it relates to AML care? 

Dr. Eisfeld:

I define personalized medicine in AML as have a complete testing at time of diagnosis that consists of not only the morphology of the bone marrow, but we call immunophenotyping, which is looking at the surface markers, but also full review of all the chromosomes, which is called cytogenetics. And with those metaphase testing, I’m looking really at all of them and at the hot spots, which is done by a technique called FISH.  

And then most importantly, for personalized testing, it also needs to consist of testing the most common, recurrent gene mutations. Changes in the tumor DNA that we know are contributing to the disease biology and also to the response of the leukemia to different genes. 

Katherine:

I imagine that personalizing therapy for a patient requires a number of tests and then thorough review of the test results. Could you provide an overview of the tests necessary to help understand a patient’s specific AML? 

Dr. Eisfeld:

Yes. Absolutely. There are multiple things that go in. And let me –even before we go into the tests – point out one thing. Because as we talk about individualized care – and it is also important to keep in mind that it will be also dependent on the age and of the performance status of the patient. 

Because we know that all the changes that are going to be reviewed might be more or less severe depending on really the age of the patient we are discussing. The most critical aspect for every AML patient is a bone marrow biopsy and a bone marrow aspirate on which the testing that I have been referring to are performed.  

One, it gives us information about how the – after review of the hematologist, it gives us information about the specific kind of the leukemic cell.  

And very importantly – and this is a very more recent development that we know about that’s important. It also tells us whether the acute leukemia is really happening as an acute leukemia or whether the patient without knowing it before might have had a precursor issue. And this is something that by now really in just about half a year we can use in addition to direct treatment.  

So, it seems like an ancient thing that we think that the microscopic review is important. But that is one part of it.  

The second part – and this is, again, all based on the bone marrow biopsy. The inspection of chromosomes, as I mentioned, may be called cytogenetics. This test takes longer. It sometimes takes up to two weeks to result. And similar, looking at the tumor DNAs and mutations that is done either if you’re at a large institution such as Ohio State or other cancer centers. It’s done in house. Whereas at smaller institutions, it would be done by a sent-out testing that has these recommended gene mutation testings done. And some of those result just within a couple of days.  

And these are – but we can talk. And I know we are going to talk a little bit more about it later, but we now have targeted therapies available. This is a really super exciting topic we couldn’t have talked about just even five years ago. And those mutations and those DNA changes come back usually within three to five days.  

So, that we are able to decide on treatment. 

Katherine Banwell:

How can someone ensure they’re getting an accurate diagnosis? 

Dr. Eisfeld:

That’s a very good question. I think the most important part is to go to somebody who has seen acute leukemias as a living. It is a very rare cancer as you know. And if you are seen even by a general oncologist who might be a fantastic oncologist, he might just see one or two cases per year. And thus, might not be up-to-date on the newest recommendations. So, I can just advise anybody – even if he lives further away and trusts his physician a lot – to – for the diagnosis and for treatment planning, come to a comprehensive cancer center, at least for a therapy planning. Because what is now possible is many of these treatments is that we can just give advice.  

And then you can still receive treatment in some cases really back at home. But be sure the testing was done correctly. And really give you every option to take into consideration what the best treatment would be for you, what the best treatment is for the patient. Having this trip – which can be hours of a drive. And I appreciate this. Having that done once would be, I think, the best thing to do. 

What Are the Types of Breast Cancer?

What Are the Types of Breast Cancer? from Patient Empowerment Network on Vimeo.

Breast cancer expert Dr. Bhuvaneswari Ramaswamy shares an overview of breast cancer types and explains the standard biomarker testing that occurs following a diagnosis.

Dr. Bhuvaneswari Ramaswamy is the Section Chief of Breast Medical Oncology and the Director of the Medical Oncology Fellowship Program in Breast Cancer at The Ohio State College of Medicine. Learn more about this expert here.

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Transcript:

Katherine:

Let’s start with an essential piece that helps people thrive, understanding their breast cancer. First, what are the types of breast cancer?

Dr. Ramaswamy:          

Yeah, and I think that’s extremely critical.   Empowering you, the patient, with the knowledge of the type of breast cancers and what’s the   outcomes and why they’re getting some treatments,  and what to look for is probably one of the most important things to do. And part of it lies primarily with the providers to ensure that education   empowerment. But part of it also lies on the part of the patient to make sure they ask the right questions and learn about their breast cancer.

So, the type of breast cancers you have that are hormone receptor -sensitive breast cancer, that means your tumor would be positive for estrogen and or progesterone receptors. And it depends on estrogen and or progesterone for its growth and well-being. And then there is a HER2-positive breast cancer, which means the HER2 protein is high in your tumors and that drives the cancer cells.

And so, it’s important to understand that subtype and why we have certain treatments to improve the outcomes. And then the last one is when all those three are not there, ER, PR, and HER2. So, hence the word triple-negative breast cancers. These are the large subtypes of breast cancers that are based on these biomarkers, which are proteins that drive the growth of breast, the cancer cells. There is of course different types of breast cancer based on histology that is invasive ductal cancer, that’s very most common. The less, slightly less common is the  invasive lobular cancer, about 10 to 15 percent.

But then there are also very less than 3 percent called   metaplastic breast cancers and other types of  breast   cancers that could also be histological different subtypes.

And it’s important for you to know what type of subtype of histological or how does it look under the microscope is important for you to know as well. So, these I would say are the most important understanding of our breast cancer subtypes, at least  this much to definitely educate the patient and patient having the understanding of their cancer.

Katherine:                     

What biomarker testing is standard following a breast cancer diagnosis?

Dr. Ramaswamy:          

So, the three biomarkers that we definitely test for at this point are the estrogen receptor for strong receptors and the HER2. And, of course, there’s also  the grade that your pathologist would grade your tumor. And grade is different from stage. And that is looking at how quickly your cells are growing. And these are the basic understanding that you should have about your cancer at this point.

Considerations That Help Guide Breast Cancer Treatment Decisions

Considerations That Help Guide Breast Cancer Treatment Decisions from Patient Empowerment Network on Vimeo.

What are key factors that help guide breast cancer treatment decisions? Expert Dr. Bhuvaneswari Ramaswamy explains what is considered and explains the significance of each factor.

Dr. Bhuvaneswari Ramaswamy is the Section Chief of Breast Medical Oncology and the Director of the Medical Oncology Fellowship Program in Breast Cancer at The Ohio State College of Medicine. Learn more about this expert here.

See More from Thrive Breast Cancer

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Transcript:

Katherine:

Another key component of thriving is finding  a treatment that is right for your disease. What are the considerations that guide a treatment decision?

Dr. Waks:

Yeah, great question. So, what we just talked about,  the two things that are very important for us to make a decision, and that’s where we have come far in the last 20, 25 years, is because we are not just taking the staging.

That is anatomical staging, meaning what’s the size of your tumor and the lymph node involvement. We use those. That is important for us because that obviously changes the risk. The higher the stage, the higher risk of   recurrence. The higher the risk, we have to do more treatment to get a benefit, right? So, that’s one side. But what we have come to understand is biomarkers  are very important. That is biology of your tumor.

So, the grade, how quickly it’s proliferating although it’s not a biomarker, but it tells us a lot. And then the three important biomarkers we talked about ER, PR, and HER2. Those all are important for us to make a decision. In addition to that, we do something called a genomic testing called Oncotype  DX assay. There is also another test called   MammaPrint. These are genomic testing.

That is, we look at some of the genes that are up or downregulated in your tumor to decide whether you  are going to benefit for something called   chemotherapy or maybe just targeted therapies enough. So, these are some of the factors that we use to make a decision.

Now, do we use age and your performance status? Meaning how well you are? Do you have   comorbidities? Do you have bad diabetes? Do you have heart disease? Yes, they all go into that whole treatment decision, but the primary is made out of biomarkers and genomic testing and anatomic, and the rest are additional factors that go into our decision-making.

Katherine:

Yeah. What about metastatic disease? Are the considerations different when it comes to treatment?

Dr. Ramaswamy:

It is a little bit different because the first thing that we have to understand is when we are seeing them in stage I, stage II, stage III, which is stage IV is metastatic, stage II – we – our goal is a curator. We are trying to really throw the kitchen sink, although that’s really not what we do. We are trying to still be  tailored therapy, but we are trying to do everything we can to prevent a recurrence.

But now when you have a stage IV disease that is the cancer has   spread, that is the horses have left the  barn in the breast and has gone and settled in distant  organs and gone, our goal is to try to contain the disease. So, prevent further progression, prolong the  life and survival, and also improve quality of life. So, there are those consideration.

The biomarkers still go into consideration. We ensure we biopsy the metastatic site and look for those biomarkers. We do the genomic testing, gene sequencing of this. That will also help with our decision-making. We, of course, look for clinical trials because new novel therapies are always more important, but these are the other factors. And, of course, performance status that is how well you are,  how well your organs are functioning, and what’s your age, and how that affects your morbidity. All of those are also important.

What Questions Should Breast Cancer Patients Ask About Their Treatment Options?

What Questions Should Breast Cancer Patients Ask About Their Treatment
Options?
from Patient Empowerment Network on Vimeo.

What do breast cancer patients need to know about treatment options? Expert Dr. Bhuvaneswari Ramaswamy shares key questions that patients should ask their team about potential treatment approaches.

Dr. Bhuvaneswari Ramaswamy is the Section Chief of Breast Medical Oncology and the Director of the Medical Oncology Fellowship Program in Breast Cancer at The Ohio State College of Medicine. Learn more about this expert here.

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What Are the Treatment Options for Early Stage Breast Cancer?


Transcript:

Katherine:

What questions should patients ask about their treatment options?

Dr. Waks:

I think the most important thing is to understand what you have first. So, kind of the doctor will talk to you about what type, histological type of breast cancer you have. They’ll also talk to you about what  biomarkers you have. And they will also talk to you  about the treatment options, which could be   chemotherapy versus target therapies, and what are the outcomes from those using clinical trials. So, I think the questions that you have to ask them is that,  what do you feel like you would is right for your body, right? That’s important. That what you have some of the preconceived notions that we all carry. That bias and preconceived notions is just a normal natural way of learning. And so ask about those fears, ask about those hopes that you have. And if your hope is, “Hey, can I do as well without chemotherapy?” Ask that question. So, and it’s important to understand the side effects and the outcomes of each therapy.

It may also be important for you if you do – you really don’t want to have treatments to understand if   you don’t get treatment, what are your outcome changes? So, those are, I think, the important thing. And then what that does mean to you? What do you want out of your life? Longevity, quality of life? How long will your quality of life be affected? And how does that impact your understanding of what you want out of your life? I think those are important for you to ask and make sure you have a friend or a relative with you so that not everything is going to go in at the first or the second visit, so you have someone else who’s taking notes.