Tag Archive for: bone marrow biopsies

What Is the Role of Bone Marrow Biopsies in AML Treatment?

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What Is the Role of Bone Marrow Biopsies in AML Treatment? from Patient Empowerment Network on Vimeo.

What part do bone marrow biopsies play in acute myeloid leukemia (AML) treatment? Expert Dr. Andrew Hantel from Dana-Farber Cancer Institute and Harvard Medical School discusses the value and information gained from bone marrow biopsies, how AML characteristics can vary, and his hopes for the future of bone marrow biopsies.

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How Bone Marrow Biopsies Impact Acute Myeloid Leukemia Treatment and Care

How Bone Marrow Biopsies Impact Acute Myeloid Leukemia Treatment and Care

 Do AML Bone Marrow Biopsies Show Racial and Ethnic Variances?

Do AML Bone Marrow Biopsies Show Racial and Ethnic Variances?

 Why Is Shared Decision-Making Important for AML Patients?

Why Is Shared Decision-Making Important for AML Patients?

Transcript: 

Lisa Hatfield:

Dr. Hantel, can you explain the importance in utility of bone marrow biopsy as it relates to treatment?

Dr. Andrew Hantel:

Yeah, so bone marrow biopsies are one of the mainstays of our ability to understand where somebody’s leukemia is. And what I mean by that is somebody’s leukemia can be newly diagnosed, and we need to get a lot of the information about it. It can be somebody who’s after treatment, and we need to understand if their leukemia has responded to that treatment.

And that can take the form of, did the treatment work well enough to clear out all of the leukemia cells? And also after somebody’s blood counts have come back after the treatment has been completed, are only their good blood cells back, or has the kind of leukemia not responded adequately to treatment? And relative to the normal tubes of blood that we can get quite easily, a bone marrow biopsy,  which we don’t like to do unless it’s necessary, is something where we have a lot of additional information that we can obtain. And it’s both information that we can’t obtain from the blood and also kind of information that we can get to kind of a different degree of specificity than we can in the blood.

And so a little bit more specifically, what I mean by that is sometimes people’s blood counts will look relatively okay, and there can be a good amount of leukemia still in their bone marrow. And other times, the person’s leukemia can be in remission, but their blood counts can look low and abnormal.

And so we need to be able to tell which of those things is actually happening. And if we could tell that without doing bone marrow biopsies, we would do that every time. But, unfortunately, the bone marrow is kind of a little bit of a harbor compared to the bloodstream. And so to be able to actually look and see what’s happening kind of in the factory is really necessary. And there’s a lot of additional tests that we’re able to run, because that’s where kind of the cells are produced, and we can see at a much lower level if there’s are any hints of leukemia left.

There’s more and more interest in kind of getting good testing from the blood. And so that’s a very active area of investigation. And to be able to do that in the future, I really hope there’s a day where we don’t have to do bone marrow biopsies. But for right now, our only ability to tell how well we’re doing with somebody’s leukemia treatment is to be able to…it’s to do bone marrow biopsies and obtain kind of that really granular specific and kind of deep dive detail.

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Do AML Bone Marrow Biopsies Show Racial and Ethnic Variances?

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Do AML Bone Marrow Biopsies Show Racial and Ethnic Variances? from Patient Empowerment Network on Vimeo.

Are racial and ethnic differences shown in acute myeloid leukemia (AML) bone marrow biopsies? Expert Dr. Andrew Hantel from Dana-Farber Cancer Institute and Harvard Medical School discusses what early AML studies are showing and proactive patient advice for bone marrow biopsies.

[ACT]IVATION TIP

“…ask your doctor about what the different things that they’re looking for in the bone marrow biopsy are and kind of what they mean to you. Sometimes, they can be looking to see if the leukemia has cleared after a treatment. Sometimes, they’re looking to see if there’s a change in the mutations that they saw before in your leukemia and are seeing if you know something is different than they can now target.”

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 How Bone Marrow Biopsies Impact Acute Myeloid Leukemia Treatment and Care

How Bone Marrow Biopsies Impact Acute Myeloid Leukemia Treatment and Care

 What Is the Role of Bone Marrow Biopsies in AML Treatment?

What Is the Role of Bone Marrow Biopsies in AML Treatment?

Transcript: 

Lisa Hatfield:

With these bone marrow biopsies or the disease in general, AML in general, do you see any unique patterns with different racial or ethnic groups? Because we see so many disparities in healthcare, any way in that you see different patterns of maybe genetic mutations with AML or any differences in the general course of the disease?

Dr. Andrew Hantel:

I would say that we…there are hints of those things right now. So there are some early studies that are showing, there are a couple specific mutations that have either increased rates or decreased rates in different racial and ethnic groups. The extent to which any of those have been really done on a wide scale and also done to the extent that we can say it actually makes a difference in different groups’ outcomes we haven’t established yet. And so right now, it’s more just hints that something is a little bit different. But the extent to which that is actually changing the course of somebodies diseases hasn’t been established. And it seems like some of these changes aren’t necessarily in the same mutations that we think of as having a lot of significance in terms of altering somebody’s prognosis.

And so while it may be  activating slightly different pathways, they aren’t the ones that are, we think in our mind are the most important ones for saying how well or how not well somebody might be doing with their leukemia. There’s a lot more research that is being actively done by my colleagues both at Dana-Farber and nationally to understand that and may come that some of what I just said becomes not true, because there are new findings seen.

And that I hope that we can understand some of those differences and pathways more. But to the extent that anything actionable is done based on those things right now, the answer is no. Right now, we know that anybody can get any of these mutations, and it’s more just that a difference of when we’re looking at a population as a whole, something is a little bit more frequent in one group than another. But that can also come down to who in that group was actually included in the study that we’re doing. And whether or not that exists really across that whole population we have yet to be able to say anything about.

Lisa Hatfield:

Thank you. And do you have an activation tip regarding bone marrow biopsies? And I’ll tell you right now, if you tell patients they might one day not have to have them, they’ll be thrilled, but you don’t have to put that in your activation tip. [chuckle]

Dr. Andrew Hantel:

So my activation tip for this question is, just to ask your doctor about what the different things that they’re looking for in the bone marrow biopsy are and kind of what they mean to you. Sometimes, they can be looking to see if the leukemia has cleared after a treatment. Sometimes, they’re looking to see if there’s a change in the mutations that they saw before in your leukemia and are seeing if you know something is different than they can now target.

And just understanding a little bit more about what their thinking is and how they’re trying to help you by doing the bone marrow biopsy because we…it’s not a test anybody likes to do or have done on them. But we always do it for a good reason, and it’s to make sure that we can better control or better cure leukemia.

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How Bone Marrow Biopsies Impact Acute Myeloid Leukemia Treatment and Care

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How Bone Marrow Biopsies Impact Acute Myeloid Leukemia Treatment and Care from Patient Empowerment Network on Vimeo.

How are acute myeloid leukemia (AML) treatment and care impacted by bone marrow biopsies? Expert Dr. Andrew Hantel from Dana-Farber Cancer Institute and Harvard Medical School explains the role that bone marrow biopsies play in AML diagnosis and monitoring and how they help guide informed treatment decisions.

Download Resource Guide | Descargar guía de recursos

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Novel AML Therapy Use | Impact of Socioeconomic Status and Other Factors

Novel AML Therapy Use | Impact of Socioeconomic Status and Other Factors

 Do AML Bone Marrow Biopsies Show Racial and Ethnic Variances?

Do AML Bone Marrow Biopsies Show Racial and Ethnic Variances?

 What Is the Role of Bone Marrow Biopsies in AML Treatment?

What Is the Role of Bone Marrow Biopsies in AML Treatment?

Transcript: 

Lisa Hatfield:

Dr. Hantel, can you explain how insights gained from bone marrow biopsies impact treatment strategies for patients with AML? And how often might individuals with AML undergo these biopsies during their treatment course? And what specific objectives do these follow-up biopsies serve?

Dr. Andrew Hantel:

Sure. So bone marrow biopsies provide critical insights into the diagnosis and monitoring of AML. They help to determine the specific type of leukemia diagnosis. They help determine the effectiveness of ongoing treatments and to guide our therapeutic decisions. For people with AML, these biopsies are typically performed initially at diagnosis and then during treatment to assess response and sometimes add intervals to monitor for disease recurrence. 

The specific timing is really dependent in follow-up on what somebody’s counts are like, which treatments they’ve received, and what their options are in terms of future treatment, if that’s being considered. When somebody gets a biopsy, we look at the cells under a microscope. And we perform specific tests to look at the different characteristics of the cells like the DNA of the leukemia cells.

And together with the clinical information of the patient, such as what other conditions they might have and then their values, meaning what are their goals and what’s most important to them? The things we see under the microscope and in those tests can together inform us as to which treatments both might be effective and align with these other factors.

For instance, we had a patient last week who was in their late 70s, and the testing from their blood bone marrow saw that there was a specific mutation in their leukemia that would allow them to actually just take a pill instead of getting kind of a more complex and infusion IV medication for the treatment of their leukemia.

And so based on that test and based on that biopsy, we’re able to have that patient actually go home from the hospital and start that treatment as an outpatient and come back and forth to clinic rather than need to stay into the hospital for a different type of therapy and remain there for observation. And so understanding the results of these biopsies can really help patients and healthcare providers make informed decisions about the course of treatment and any adjustments to the therapy that might be needed.

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How Can Bone Marrow Biopsies Be Used in AML Care?

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How Can Bone Marrow Biopsies Be Used in AML Care? from Patient Empowerment Network on Vimeo.

How do AML care providers use bone marrow biopsies in patient care? Expert Dr. Sara Taveras Alam from UTHealth Houston explains how the tests are used and shares patient advice for lifestyle and dietary precautions against infections.

[ACT]IVATION Tip

“…in terms of going out in the world, I would avoid for our AML patients to be in crowded spaces, and if they are going to be in crowded spaces to use a mask so that they’re protected from respiratory infection.”

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Transcript: 

Lisa Hatfield:

Dr. Taveras, can a bone marrow biopsy be used to monitor response to treatment in AML, and are there other tests to help monitor treatment and kind of a unique question, are there any specific dietary or lifestyle recommendations for patients undergoing a bone marrow biopsy or diagnosed with AML?

Dr. Sara Taveras Alam:

Well, the response to treatment in AML is measured with a bone marrow biopsy as the best test to assess response; however, we can have a clue into the response based on the blood test for the patient, so typically patients with acute myeloid leukemia will have anemia and thrombocytopenia, so low hemoglobin, low platelets and will likely be needing transfusions for this. 

Sometimes patients with acute myeloid leukemia will have an elevated white blood cell count or low white blood cell count. Ideally, if a patient has responded to treatment, we would see the hemoglobin and platelets improving and less transfusion requirements. They might not normalize that, they would usually improve if there is response to treatment, and similarly, when it comes to the white blood cells, if the patient has responded to treatment, ideally the white blood cell count should normalize and you should not be seeing any abnormal immature blood cells in the blood work, so we should not be seeing any blasts and ideally we would be having…I’m sorry, a good number of healthy white blood cells.

So that is a surrogate marker for the bone marrow biopsy to assess response, how is the patient doing? What symptoms are they having? What is their CBC or blood count looking like? Ultimately, the bone marrow biopsy is the best test, because then we look at the place where the blood cells are being born and confirm that the blast count has been eradicated, that we see no blasts or at least less than 5 percent, which would be what we call a morphologic remission, then we do deeper assessments by sending the tests about the karyotype or chromosomes that are driving the disease and the mutations that could be driving the disease.

Ideally, if the patient has a very good response, all of those should be gone, sometimes the mutations are still there, but we’re not seeing the deceased being active, and really the bone marrow biopsy will guide the treatment to see if we’re in the right trajectory, if we can continue whatever treatment the patient is on or if we need to switch gears and treat with a different regimen to get the disease back in control.

As it relates to specific dietary or lifestyle recommendations for patients undergoing bone marrow biopsies, I wouldn’t say that there are any specific recommendations for that. On occasion, if a patient is on a blood thinner, they may be asked to stop the blood thinner for the bone marrow biopsy. Of course, that depends on what the indication for the blood thinner is. But in terms of dietary lifestyle changes, I don’t think that any change is necessary.

In terms of patients overall going through acute myeloid leukemia in terms of lifestyle recommendations, it is recommended that the patient be extra careful with infections because they are at higher risk for infection and this may mean different things at different stages of treatment and may be guided by what blood counts are looking like, specifically the neutrophils, which are the healthy white blood cells that help protect us from infections.

So patients that are neutropenic, meaning have low neutrophil count are at really high risk of infections, and we recommend for them to avoid undercooked meat or raw seafood, for example, ceviche or sushi. Any meat should be well cooked and any vegetables have to be very clean, very washed, so that we eliminate the risk of infection.

Oftentimes, I tell my patients to stick to cooked vegetables rather than raw because, unfortunately, if there is some bacteria, then the risk for our patients is much higher than the general population. Additionally, in terms of going out in the world, I would avoid for our AML patients to be in crowded spaces, and if they are going to be in crowded spaces to use a mask so that they’re protected from respiratory infection.

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AML Diagnosis | Exploring Bone Marrow Biopsy and Alternatives

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AML Diagnosis | Exploring Bone Marrow Biopsy and Alternatives from Patient Empowerment Network on Vimeo.

What are the purpose and alternatives to bone marrow biopsy? Expert Dr. Sara Taveras Alam from UTHealth Houston explains what’s involved in bone marrow biopsy, what is analyzed, patient advice for the procedure, and alternative testing methods.

[ACT]IVATION Tip

“…ask the providers what to expect from the bone marrow in the facility where you are in. Usually in all facilities, lidocaine, or local anesthesia is used, but if you foresee that in general, you are anxious about procedures or susceptible to pain, you are welcome to request for some medications for pain and anxiety to help you get through that procedure, and generally, once patients have undergone a first bone marrow biopsy, they know what to expect and what accommodations may be needed for them in subsequent bone marrow biopsies.”

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Advancements in AML Treatment | Tailoring Therapies to Individual Patients

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Transcript: 

Lisa Hatfield:

Dr. Taveras, what specific features are pathologists looking for in the bone marrow sample when diagnosing AML, and are there any alternative diagnostic methods or tests available for AML besides a bone marrow biopsy?

Dr. Sara Taveras Alam:

And that is a great question. I think that many patients may be scared of what bone marrow biopsy entails. It is a procedure after all, and it can be painful. I do know that they’re able to get some details about the diagnosis from the peripheral blood just from blood tests alone; however, the best diagnosis is performed through the bone marrow biopsy, so it can provide more information about the email, than what we’re able to obtain from the blood, sometimes the blood count, the white blood cell counts are elevated in AML and that may make it easy to do some of our testing from the blood work, but in other patients, the white blood cells may be low at presentation and that can make it very difficult to obtain any meaningful diagnostic and prognostic information without a bone marrow biopsy.

The bone marrow biopsy would also allow to tell if the patient had a preceding blood disorder like a myeloid dysplasia and this may have treatment implications. This is not something that we would be able to tell from the blood alone unfortunately, so when our pathologists look at the bone marrow sample, they are looking at some of the blood that is obtained from that boom marrow space where the blood is produced, and a tiny piece of the bone from there as well, and they’re looking at the amount of cells, especially the normal red cells, the normal white blood cells, normal platelets, and specifically the abnormal white blood cells or blasts that are quantified in a percentage fashion to diagnose the AML.

There are also different types of blasts, so they may be able to sub-classify the AML from just looking at the morphology or how these cells look under the microscope. There are many ancillary tests that are performed on the sample as well to look into the genetics for the driving forces behind the acute myeloid leukemia.

We look at a chromosome analysis to see what the chromosomes are for the leukemia. We look at mutations during FISH testing, and we do molecular testing that are looking at specific point mutations that may be associated with AML and provide insight into the treatment options as well as the prognosis, the patient’s disease, and whether or not they may benefit from a stem cell transplant to increase the chances of maintaining a remission and obtaining a cure.

My advice for patients who may be anxious about the bone marrow biopsy would be to voice their concerns for their providers. I believe that different centers have different practices as it relates to pre-medication, so some places may provide anxiety medications and pain medications in advance of the procedure, but some other facilities may not. So my activation tip for this question is to ask the providers what to expect from the bone marrow in the facility where you are in.

Usually in all facilities, lidocaine, or local anesthesia is used, but if you foresee that in general, you are anxious about procedures or susceptible to pain, you are welcome to request for some medications for pain and anxiety to help you get through that procedure, and generally, once patients have undergone a first bone marrow biopsy, they know what to expect and what accommodations may be needed for them in subsequent bone marrow biopsies.

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A CLL Expert Addresses Common Clinical Trial Misconceptions

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A CLL Expert Addresses Common Clinical Trial Misconceptions from Patient Empowerment Network on Vimeo.

CLL patients and care partners often have misconceptions about clinical trials. CLL expert Dr. Adam Kittai addresses common patient questions and concerns about trials.

Dr. Adam Kittai is a hematologist and an assistant professor at the The Ohio State University Comprehensive Cancer Center – The James. Learn more about Dr. Kittai, here.

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Transcript:

Katherine:

Right. So, I’d like to walk through a few common questions that patients have about clinical trials. And here’s a concern we received from a patient prior to the webinar. “I’m nervous that I will receive a placebo if I join a clinical trial.” So, first of all, would you define a placebo? 

Dr. Kittai:

Sure. A placebo is usually a sugar pill or something that has no effect. That’s what a placebo is.  

Katherine:

And is it true then, would a patient possibly get a placebo in a CLL clinical trial? 

Dr. Kittai:

Not typically. So, in terms of clinical trials for CLL, we have a lot of treatments that are effective and safe in CLL. And so, we don’t typically design trials where you’re not getting some kind of active therapy. It would be extremely rare, and I don’t know of any trials currently that involve patients getting a placebo for CLL. Because it wouldn’t be ethical for us to enroll a patient on a trial where they would get a placebo instead of active therapy. 

Katherine:

Here’s another question from an audience member, and I think this is probably a common concern for patients. “Is a clinical trial only something I should consider if there are no other options?” 

Dr. Kittai:

So, in my opinion, you should always consider a clinical trial, even if there are other options. And it’s because of those two reasons that I mentioned earlier. Number one, it benefits the CLL community as a whole to participate in the trial so that way doctors and researchers can collect data to improve outcomes for patients with CLL. And also, even though our drugs currently work really well, we don’t know how well they’ll last for, right? So, they still don’t know for certain how long our current drugs are going to work for in the future.  

And we’re always trying to do better. We’re always trying to create some sort of treatment, some sort of treatment paradigm that might be safer, as well as work better, and either of those goals is approvable. All of our drugs come with toxicity, right? And even though they’re really safe and they work really well, we’re hoping to develop something that is even safer and works even better.  

Katherine:

Yeah. It sounds, then, like trials can be considered throughout a patient’s life with CLL. What concerns do you hear from your patients?  

Dr. Kittai:

Yeah, so I think the primary concern I hear about a trial and the difference between going on a trial and standard of care, is that typically for a trial, it does require a little bit more from the patient. Meaning that there’s usually more visits – whether it is to monitor the effect of the new medication or new medication combination on the patient, whether or not it’s affecting their laboratory values or how they’re feeling.  

Or there might be parts of the trial that require invasive procedures. So, for instance, many trials will require bone marrow biopsies where a standard of care won’t. And the reason why the collection of those bone marrow biopsies is important for the trial is to better get an idea of how the treatment is working on a patient’s body.  

So, I think those are the two primary concerns I hear from the patient. Number one, it typically is a bigger time commitment with more visits to the doctor because we have to closely monitor the patients while they’re on trial. And number two is sometimes the trial involves procedures that otherwise wouldn’t be indicated for standard of care.  

How Is AML Treatment Effectiveness Monitored?

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How Is AML Treatment Effectiveness Monitored? from Patient Empowerment Network on Vimeo.

How can acute myeloid leukemia (AML) treatment effectiveness be monitored over time? Expert Dr. Ellen Ritchie explains when testing is typically done following AML treatment, which methods are used for monitoring, and when retesting may be appropriate.

Dr. Ellen K. Ritchie is assistant professor of medicine and a member of the Leukemia Program at the Weill Cornell Medical College of Cornell University and the New York Presbyterian Hospital. More about Dr. Ritchie, here.

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Transcript:

Katherine:

Once a patient has begun treatment, how do you monitor whether it’s working?

Dr. Ritchie:

So, one of the more frustrating things about being an AML patient, is you don’t know right off the bat whether or not that you have gone into remission. So, what happens is you receive the chemotherapy, and the day you start chemotherapy is really day one. And somewhere around day 14, you’re at your lowest point. So, your blood counts are low, and you often feel really terrible, and you really wonder, is this working? But unfortunately, I can’t really tell you. Some institutions do bone marrow biopsies if you have intensive chemotherapy on day 14, or if you’re getting venetoclax (Venclexta) therapy somewhere around day 21 to look and see whether they still see leukemia cells, but the utility of that is different per institution.

The real test of whether chemotherapy x, is at the end of about 28-35 days, are your blood counts coming up, and are you making normal blood cells. Are you making platelets, which are the part of the blood that clots the blood? Or are you making neutrophils, which are the important cells needed to help you fight infection. So, the real proof of a remission, is are your platelets over 100,000? Is your neutrophil count over 1,000? And when we look in the bone marrow around that time, do we see normal cells developing and no leukemia?

Katherine:

How often should testing take place? And should patients be retested over time?

Dr. Ritchie:

So, the bone marrow biopsy is done frequently once you have a diagnosis of acute leukemia. So certainly, it’s done upon diagnosis of the disease.

And as I mentioned earlier in certain institutions, about halfway through your chemotherapy cycle, they’ll do a bone marrow biopsy to see whether or not they see any residual leukemia cells. That’s not done everywhere, and it’s done differently depending upon institutions sometimes. At the end of the chemotherapy treatment, if you recover your blood counts, we do a bone marrow biopsy to confirm a remission. If by day 35, we haven’t seen that your blood counts are recovering, we may do a bone marrow biopsy to see whether or not we see leukemia cells in there, or early recovery. So, you’re definitely going to have bone marrows at those time points. If you’ve gone into remission, it depends on what we’d do next as to when you would have another bone marrow biopsy. So, if you’re going to bone marrow transplant you may have one more biopsy, just prior to going into transplant, and another biopsy at the end of the first month after transplant.

If you’re going to have what we call ongoing therapy, roughly every three or four months, we may do a bone marrow biopsy to determine whether or not the remission is holding. If during ongoing therapy, we see that there is blood count abnormalities that we weren’t expecting, that might be a reason that we would do a bone marrow biopsy. And that’s unpredictable as to when that would be.