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An Expert Review of DLBCL Research and Treatment Advances

An Expert Review of DLBCL Research and Treatment Advances from Patient Empowerment Network on Vimeo.

What’s the latest in diffuse large B-cell lymphoma (DLBCL) treatment advances? Expert Dr. Robert Dean provides an update about emerging DLBCL research and explains recent treatment approvals for relapsed DLBCL patients.

Dr. Robert Dean is a hematologist/medical oncologist at Taussig Cancer Institute at the Cleveland Clinic. Learn more about Dr. Dean, here.

See More From The Pro-Active DLBCL Patient Toolkit


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Transcript:

Katherine:

Is there emerging DLBCL research that you feel patients should know about?

Dr. Dean:

I would say, “yes.” One of the things that has really been striking for me in the last few years alone in caring for patients with large B-cell lymphoma is how we’ve gone from a more surface-level understanding as we’ve been talking about what some of the differences are between different cases of large B-cell lymphoma to being able to get a better readout of why the lymphomas sometimes behave the way they do.

I want to be careful to make sure that patients who might be listening to this understand that we still don’t have a crystal ball. We can’t review their biopsy, look at their scans, and tell you, “I know that if you get R-CHOP you’re going to be cured.” Or if they’re a high-risk situation we can’t look into a crystal ball and tell them, “I know that R-CHOP won’t work for you, and you should do this tougher, more intensive treatment.”

We still see a lot of outcomes that we can’t necessarily predict from those other kinds of tools. They just give us a better sense of what the odds are for people as we’re at the start trying to make decisions about what to do. Another element that has really been striking has been the introduction of engineered T-cell immune therapy, which has provided an option for cure for some patients that otherwise we wouldn’t have had an option, and worked for about half the patients that go through it overall.

What’s coming down the road in clinical trials that are still ongoing is information that’ll help us decide if that approach to treatment should move to being second in line instead of a stem cell transplant for some patients, and they’re even doing studies looking at whether, for very high-risk patients, adding a CAR T-cell treatment onto the end of initial chemotherapy leaves them better off in the long run.

So, those are questions that will take some time to answer with ongoing studies, but I think are really exciting because they’re taking advantage of some of these newer treatment approaches that we know are helping some patients when their first attempts at treatment didn’t work and seeing if they might leave them better off if we use them earlier in the process.

There are other studies ongoing looking at seeing if we can improve upon the results that we get with treatments like R-CHOP as the first pass at treatment. Many such studies have been done and have not shown any benefit by adding this drug or that to the standard R-CHOP treatment, but there have been a few new drugs approved for treating people with large B-cell lymphoma after it’s relapsed in the last few years. For example, one called polatuzumab vedotin. Another combination of the drug lenalidomide and a new antibody-based drug called tafasitamab.

And then there’s another drug called loncastuximab. So, there’re studies going on with all of those looking at whether they offer more benefits to patients if we use them earlier in the game. 

Key Steps Following a DLBCL Diagnosis

Key Steps Following a DLBCL Diagnosis from Patient Empowerment Network on Vimeo.

What are key steps to take after a diffuse large B-cell lymphoma (DLBCL) diagnosis? Expert Dr. Robert Dean shares advice for newly diagnosed DLBCL patients to access optimal care.

Dr. Robert Dean is a hematologist/medical oncologist at Taussig Cancer Institute at the Cleveland Clinic. Learn more about Dr. Dean, here

See More From The Pro-Active DLBCL Patient Toolkit


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Should DLBCL Patients Consider a Second Opinion?


Transcript:

Katherine:

Yeah, of course. What three key pieces of advice would you have for a patient who’s just been diagnosed with DLBCL?

Dr. Dean:

The first, I would say, is always consider getting a second opinion. I would say that’s true for a patient who’s receiving care with a local oncologist who sees and treats all forms of cancer and who’s very close to home. But I would say that’s true for someone who comes and sees me as an oncologist who treats only lymphoma patients. You should never worry about hurting your doctor’s feelings by going and talking to someone else to get another perspective on their case. The second is that they should make sure that their biopsy has been checked for the other tissue-based predicting factors that we talked about earlier that can help give a better idea of whether their chances of cure are higher or possibly lower with standard R-CHOP treatment.

And if they’re in a higher-risk group that might have a lower chance of cure with R-CHOP, then they should ask, “should I be receiving a different kind of treatment?” And then, the third thing I would say is, they should always ask, “is there a clinical trial that’s a good fit for my situation. And if there isn’t one here, is there one somewhere else that’s worth me considering even if it might mean me traveling somewhere?”

Katherine:

Right.

Dr. Dean:

There’re always a lot of clinical trials around. And if there’s a good clinical trial that’s a fit for someone’s medical situation, and I would say, if it’s pretty close to the care that they need already and is asking an additional question and possibly providing an additional element to the treatment that may be helpful and that will help us learn something along the way, then in my mind that’s the best-case scenario. 

Relapsed DLBCL Treatment: What Are the Options?

Relapsed DLBCL Treatment: What Are the Options? from Patient Empowerment Network on Vimeo.

What are the treatment options for relapsed diffuse large B-cell lymphoma (DLBCL)? Expert Dr. Robert Dean explains approaches for relapsed DLBCL patients and considerations that may alter the treatment course. 

Dr. Robert Dean is a hematologist/medical oncologist at Taussig Cancer Institute at the Cleveland Clinic. Learn more about Dr. Dean, here.

See More From The Pro-Active DLBCL Patient Toolkit


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Transcript:

Katherine:

Are treatment considerations different for patients with relapsed disease?

Dr. Dean:

I’d say that they’re similar in a lot of ways. The first is, in my mind, again, is the patient that I’m seeing somebody who could potentially tolerate treatment that would be given with the goal of trying to cure their lymphoma on a second try?

Some patients with relapsed large B-cell lymphoma can be cured with the most common standard second-line approach, which is to get them back into remission with some standard chemotherapy, and then to follow that with a very intensive course of high-dose chemotherapy as a one-time treatment that’s given with a stem cell transplant using the patient’s own preserved healthy bone marrow stem cells. That treatment’s effective in about half of patients that can undergo it and you need to be pretty fit medically and in an overall physical sense to be able to get through that treatment okay and have a good healthy recovery afterward.

So, it’s not for everyone, but it is doable in a lot of patients. The other questions or considerations that I think are important are if a patient is sort of on the border in terms of their overall health and their willingness to undergo really rigorous intensive treatment as a second try.

We have to look, in a balanced way, at what their goals are as an individual and what it’s going to take for them to try to reach those goals. I don’t easily back away from recommending to someone that I think has a shot at cure that they should go for it if they’re medically in reasonable shape to try for that. But there’re some people who, after their initial course of treatment, decide that they don’t want to pursue intensive treatment anymore and would rather go with a lower-intensity approach that might not have the potential for cure, but that wouldn’t be as demanding of them physically or logistically.

The logistics are another factor for some patients because most patients with large B-cell lymphoma can get treated with a standard treatment approach like R-CHOP as their initial treatment at someplace that’s easily accessible to them where they live.

But the advanced treatments that are used to try to cure patients with relapsed large cell lymphoma, like a stem cell transplant, or like engineered CAR T-cell therapy, are only offered at large hospital-based cancer centers. And for some people, signing up to go and undergo that kind of treatment, to go through a long hospital stay, to be far away from family and home for a long time like that, and then have a longer recovery afterward, is something that they aren’t always comfortable with and really need some coaching through to figure out how all that aligns with their goals.

Most people, in my experience, are willing to go through what they have to if we think, and if they feel like, they’ve got a decent shot at getting cured on a second try. But that’s part of the discussion that we have when we’re talking about what their options are because there are less intensive approaches available.

They just don’t carry that same potential for cure.

Factors That Guide a DLBCL Treatment Decision

Factors That Guide a DLBCL Treatment Decision from Patient Empowerment Network on Vimeo.

What factors impact diffuse large B-cell lymphoma (DLBCL) treatment decisions? Expert Dr. Robert Dean shares key considerations, such as a patient’s health and risk factors, in determining DLBCL treatment options.

Dr. Robert Dean is a hematologist/medical oncologist at Taussig Cancer Institute at the Cleveland Clinic. Learn more about Dr. Dean, here.

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How Does Your DLBCL Subtype Impact Your Treatment Options?

 

 

 

Transcript:

Katherine:

What are the main factors you take into consideration before a treatment approach is decided on?

Dr. Dean:

From the perspective of the biology of the lymphoma itself, it’s making sure that the tissue samples have been worked up in a thorough enough way to give us the information that we’ve already been discussing, especially to rule out or to identify when there’s a double-hit kind of chromosomal change in the lymphoma cells because for most patients that abnormality does call for a different approach from the usual R-CHOP treatment.

And not all treatment centers are equipped to give those more intensive treatments. So, someone who’s got a standard and, what I would consider to be a lower-risk case of large B-cell lymphoma, could be served very well receiving standard outpatient R-CHOP chemotherapy under the care of a local oncologist who’s taking care of patients in their community.

But someone who’s got a higher-risk situation, like a double-hit large cell lymphoma, would probably be better served to at least be seen in consultation by someone who’s got more specialized expertise in treating higher-risk lymphoma patients at a referral center. Beyond that, you have to also take into account a number of patient factors. Because diffuse large B-cell lymphoma is potentially curable with standard treatments, even the high-risk cases that’s true.

The first question that I always ask myself when I’m evaluating a new patient is, “is there anything about this person’s health that would make it impossible or highly risky for them to tolerate the standard treatments that we use to try to cure our patients?” If they’re a candidate for curative-intent treatment, then we decide what the most appropriate treatment would be from there.

The second question is, as we talked about before, is R-CHOP a reasonable standard approach for that patient, or do they have other risk factors that would suggest that you’d need to do something different, such as rituximab and EPOCH treatment or another more intensive regimen for a double-hit case? There’s a subgroup of patients who have large cell lymphoma that arises in the testicle in men and those patients are at increased risk for having the lymphoma show up later as a recurrence in the nervous system. There are studies that suggest that if you add some elements to the treatment to try to prevent that, that it may reduce that risk.

Katherine:

Okay.

Dr. Dean:

And then I think the last thing I would say is, with any patient I consider, are they eligible for a clinical trial that’s looking at a novel approach to treating large cell lymphoma and, if there is a clinical trial that they’d be eligible for, is that a good fit for their situation?

We know that our best treatment approaches that we currently have for standard of care right now still don’t prevent relapses in some patients and we want to continue to be able to offer our patients better treatment approaches and the only way that we can do that is by testing new ideas in clinical trials. So, I always ask myself, “Is this patient eligible for a trial, and do we have a trial or do I know of a trial that would be a good fit for them?” 

How Does Your DLBCL Subtype Impact Your Treatment Options?

How Does Your DLBCL Subtype Impact Your Treatment Options? from Patient Empowerment Network on Vimeo.

How does a patient’s diffuse large B-cell lymphoma (DLBCL) subtype impact their treatment options? Expert Dr. Robert Dean explains the most widely used DLBCL treatment approach as well as options for highly aggressive subtypes.

Dr. Robert Dean is a hematologist/medical oncologist at Taussig Cancer Institute at the Cleveland Clinic. Learn more about Dr. Dean, here.

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Transcript:

Katherine:

So, how does a patient’s subtype impact their treatment options?

Dr. Dean:

It’s getting there slowly. Right now, the most widely used initial treatment for patients with diffuse large B-cell lymphoma is still the monoclonal antibody rituximab (Rituxan) and the combination chemotherapy regimen called CHOP, or R-CHOP as it’s called for short all together. And for patients with lymphomas that are not the so-called double-hit type, at least in our center, R-CHOP is still the standard, most commonly used approach to treat those cases. For the double-hit cases, studies have shown that their results with R-CHOP treatment are significantly worse than what you see with the cases that are not double-hit lymphomas.

And because of that, a lot of lymphoma treatment programs have looked to other approaches to treatment that are a little more intensive, similar to what we use for highly aggressive lymphomas, such as Burkitt lymphoma, to see if we can do better for those patients. And the one that we most commonly use here at our center for the double-hit lymphoma cases is a regimen that’s called R-EPOCH, where you take the drugs that are in the R-CHOP, add an extra chemotherapy medicine, and give them in a different manner that provides a more prolonged exposure to the chemotherapy drugs with each round of treatment and also provides for some tailoring of the chemotherapy doses from one round of treatment to the next.

There aren’t any great controlled trials yet that prove that stronger treatment regimens like R-EPOCH are better for the double-hit cases of large cell lymphoma than the tried-and-true R-CHOP regimen that’s used for most other situations.

But there are what we call uncontrolled studies or retrospective studies that have looked at patients treated with those higher intensity regimens, and they at least suggest that patients treated with those approaches look like they do better than what you would have expected with the R-CHOP approach. And then there are a few less common subtypes of large cell lymphoma that are more specific and are treated in more unique ways.

For example, large B-cell lymphoma can arise in the brain only in rare cases and when that occurs it’s treated using an approach that’s really geared toward ensuring that you’re giving chemotherapy drugs that can effectively get into the brain tissue and attack the lymphoma cells there. Once in a while, you see someone who’s got both of those situations going on at once, lymphoma growing in the lymph node system or other places in the body outside of the nervous system, and lymphoma growing in the nervous system at the same time, and you need to make adjustments in how you treat those cases, too. 

What Are the Subtypes of DLBCL?

What Are the Subtypes of DLBCL? from Patient Empowerment Network on Vimeo.

What are the subtypes of diffuse large B-cell lymphoma (DLBCL)? Expert Dr. Robert Dean provides an overview of DLBCL subtypes and how treatments and outcomes can vary by a patient’s individual disease.

Dr. Robert Dean is a hematologist/medical oncologist at Taussig Cancer Institute at the Cleveland Clinic. Learn more about Dr. Dean, here.

See More From The Pro-Active DLBCL Patient Toolkit


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What Is Diffuse Large B-cell Lymphoma (DLBCL)?


Transcript:

Katherine:

Dr. Dean, welcome. Would you please introduce yourself?

Dr. Dean:

Certainly, and thank you for having me. My name’s Rob Dean, and I’m a hematologist and medical oncologist and a staff physician at the Cleveland Clinic Taussig Cancer Institute.

Katherine:

Excellent. Thank you. Let’s start with looking at understanding and treating DLBCL. What are the subtypes of DLBCL?

Dr. Dean:

The classification of diffuse large B-cell lymphoma has gotten a little more complicated as our understanding of it has gotten deeper. Once upon a time going back maybe 15, 20 years an awful lot of cases were sort of lumped together under the broad label of diffuse large B-cell lymphoma and we always understood in the field that some patients did very well and were cured with the standard treatments of the time and that those treatments didn’t work as well for some patients.

And it’s taken years to get to a somewhat deeper understanding of what the underlying differences are in those cases that help to explain why our treatment outcomes differ for different patients, and I would say that’s feeding forward into trying to identify better treatment options for the patients who are in higher-risk groups. So, one way of understanding the heterogeneity in diffuse large B-cell lymphoma, the differences between cases, is to think about the way in which the normal cells of the immune system that turn into this kind of cancer develop. If you think about the old Time-Life Magazine illustration of the evolution of man where you see the series of figures drawn from left to right going from sort of more primitive, kind of a –

Katherine:

Ape-like.

Dr. Dean:

– ape-like figure to a progressively more modern-looking human standing upright and walking on just their legs. The way that these immune cells, which are the antibody-making B cells of the immune system, develop from a more primitive cell, you can think of it in similar terms. And we understand that cases of diffuse large B-cell lymphoma most commonly arise from a couple of points in that process of maturation that these cells are passing through as they go from the most primitive form that they take to their most mature functional form in the end.

So, one of those subgroups is something called the germinal-centered B-cell. And that involves the part of the maturation process where these immune cells have left the bone marrow, passed into a lymph node, and are interacting with other immune cells as part of their education and development process.

When the cells mutate at that stage of their development and turn into diffuse large B-cell lymphoma, the cure rate for patients with large cell lymphomas coming from that stage of immune cell development tends to be a little higher with standard treatments. When the lymphoma cells arise from an immune cell that has passed beyond that point in the maturation process to what is referred to as an activated B-cell, then the cure rates with standard treatment historically have been a little lower.

And so, you can look at markers on the lymphoma cells, or the activation of different genes in the lymphoma cells, to try to determine whether they came from an immune cell that was in one or the other of those points in its maturation process. And we know that that correlates with outcomes. So, that’s one of the main breakdowns that have become possible in understanding sort of what’s going on under the hood in diffuse large B-cell lymphoma and why do we see different outcomes in different patients.

Katherine:

Right.

Dr. Dean:

The other major change comes from understanding that for cases of large B-cell lymphoma there are common chromosomal changes that result in turning on specific genes. And if some of those genes are present in the right combination, that can create a much more rapidly growing and more chemotherapy-resistant form of large B-cell lymphoma. The two genes that are most commonly involved in that kind of a change are something called BCL-2 which, when it’s turned on abnormally, helps protect the lymphoma cells from being killed or being sort of triggered into dying by chemotherapy medicine.

And another gene that’s called MYC, or M-Y-C is how that’s spelled, and what that gene does is it tends to cause the cells to proliferate more rapidly.

It turns on other pro-survival figures and controls a pretty broad range of different programs that drive the cells to grow more quickly. So, when you’ve got both of those changes at the same time that’s sometimes referred to as a “double-hit lymphoma.” And large cell lymphomas with that double-hit kind of chromosome change have been shown in studies to have a significantly lower cure rate with our most commonly used standard treatment for this form of lymphoma, what we call R-CHOP.

So, being able to recognize those changes in cases of large B-cell lymphoma is important nowadays, both in terms of being able to share prognostic information with patients, to be able to tell them what we think the likelihood of not just getting into remission but eventually being cured will be. And also, for some situations, considering whether a treatment other than the standard R-CHOP regimen might be a better option. 

Is the COVID-19 Vaccine Safe and Effective for People With Colon Cancer?

Is the COVID-19 Vaccine Safe and Effective for People With Colon Cancer? from Patient Empowerment Network on Vimeo.

Dr. Smitha Krishnamurthi, a colon cancer specialist at Cleveland Clinic, provides vaccine safety information and discusses the effective immune response after COVID-19 vaccination in patients with colon cancer.

Dr. Smitha Krishnamurthi is a gastrointestinal medical oncologist at the Cleveland Clinic. Learn more about Dr. Krishnamurthi here.

See More From The Pro-Active Colon Cancer Patient Toolkit


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Transcript:

Katherine Banwell:

Is the COVID vaccine safe and effective for people with colon cancer?

Dr. Krishnamurthi:

Yes. The COVID vaccine is safe. We have no data that patients with colorectal cancer or patients who are undergoing chemotherapy are at any increased risk of any side effects from the vaccine. People should be able to make a good immune response. Patients who are not able to make a good immune response are those who are getting very high-dose chemotherapy, like a bone marrow transplant or an organ transplant. But chemotherapy for colorectal cancer should not be problem. We basically advise – I ask all my patients to get the vaccine. They should just get it whenever they can. They don’t have to worry about timing in regards to their chemotherapy.

Katherine Banwell:

Okay. Dr. Krishnamurthi, thank you so much for joining us today.

Dr. Krishnamurthi:

Katherine, thank you so much for having me. It’s been such a pleasure.

Colon Cancer Treatment and Research News

Colon Cancer Treatment and Research News from Patient Empowerment Network on Vimeo.

What’s the latest colon cancer treatment and research news from the American Society of Clinical Oncology (ASCO) meeting? Dr. Smitha Krishnamurthi shares updates about research findings that were presented at the meeting along with exciting ongoing research in colon cancer.

Dr. Smitha Krishnamurthi is a gastrointestinal medical oncologist at the Cleveland Clinic. Learn more about Dr. Krishnamurthi here.

See More From The Pro-Active Colon Cancer Patient Toolkit


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Should Your Family Members Be Screened for Colon Cancer?


Transcript:

Should Your Family Members Be Screened for Colon Cancer?

Should Your Family Members Be Screened for Colon Cancer? from Patient Empowerment Network on Vimeo.

When should members of your family get colon cancer screening? Dr. Smitha Krishnamurthi from Cleveland Clinic shares screening guidelines for family members and discusses the necessity of genetic counseling.

Dr. Smitha Krishnamurthi is a gastrointestinal medical oncologist at the Cleveland Clinic. Learn more about Dr. Krishnamurthi here.

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Transcript:

Katherine Banwell:

If you’ve been diagnosed with colon cancer, what is the guidance for screening family members, such as children and siblings?

Dr. Krishnamurthi:

Yes, this is an excellent question. We tell all our patients who have been diagnosed with colorectal cancer that their first-degree relatives should start screening by age 40, but also 10 years younger than the youngest affected member of the family. So, whichever is younger.

If my patient is 45, definitely that person needs to have genetic counseling because they’re young for colorectal cancer. Then we’d recommend at least start by age 35 for their children or siblings, even if no inherited cause is found.

Katherine Banwell:

Okay, all right.

How Speaking Up Can Positively Impact Your Colon Cancer Care

How Speaking Up Can Positively Impact Your Colon Cancer Care from Patient Empowerment Network on Vimeo.

Why should you advocate for the best care for you? Dr. Smitha Krishnamurthi, a colon cancer specialist from Cleveland Clinic, provides key advice to access better care, including the value of second opinions, and why you should feel empowered to speak up.

Dr. Smitha Krishnamurthi is a gastrointestinal medical oncologist at the Cleveland Clinic. Learn more about Dr. Krishnamurthi here.

See More From The Pro-Active Colon Cancer Patient Toolkit


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Transcript:

Katherine Banwell:

What is your advice to patients who may feel like they’re hurting feelings by seeking a specialist or even a second opinion?

Dr. Krishnamurthi:

I would advise patients to not worry about that at all. I think that any one of us diagnosed with colorectal cancer would want a second opinion, would want to make sure that we’re getting an opinion from a high-volume cancer. Working here are Cleveland Clinic, I have the luxury of focusing on treatment of gastrointestinal cancers, whereas my colleagues who are in the community are treating patients with all different types of cancers. They have to be knowledgeable in all different types of cancers.

I think that’s actually much harder. I think that if your oncologist is not a specialist, the oncologist may actually appreciate having an opinion from a specialist, which helps them as well.

I think that if the doctor is going to be offended, then that’s probably not the right doctor to see. I think it’s important to just advocate for oneself and go for it.

Katherine Banwell:

That leads to my next question. What advice do you have about self-advocacy, about speaking up for yourself as a patient?

Dr. Krishnamurthi:

I think that’s very important to feel comfortable with your treatment team, with the doctor, nurse, nurse practitioner. If you have the luxury where you have choices where you live, seek out somebody who you can really connect with. I think it’s very important for the treating team to know what the patient is going through.

We have to know how the treatment is going so that we’re dosing properly, making adjustments. We want to know what our patient’s goals are so that we’re providing the best quality care.

I think it’s helpful to bring somebody to appointments. Or if you can’t bring somebody, you’ll call them on the phone. We’re doing that a lot now. People are joining by video call or even speaker phone. Many offices will have a speakerphone. You can ask to have somebody called on your behalf. Especially with COVID and the restricted visitation. Let’s get people on the phone. Somebody else to listen for you. For the patient, I mean, and to take notes. That really helps

Newly Diagnosed With Colon Cancer? Key Advice From an Expert

Newly Diagnosed With Colon Cancer? Key Advice From an Expert from Patient Empowerment Network on Vimeo.

Dr. Smitha Krishnamurthi, a colon cancer specialist from Cleveland Clinic, shares steps to take following diagnosis to ensure patients are receiving optimal care.

Dr. Smitha Krishnamurthi is a gastrointestinal medical oncologist at the Cleveland Clinic. Learn more about Dr. Krishnamurthi here.

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Transcript:

Katherine Banwell:

What three key pieces of advice would you have for a patient who has just been diagnosed with colon cancer?

Dr. Krishnamurthi:

Okay. Yes, when somebody received a diagnosis of colon cancer, of course it’s a very serious diagnosis. I would always encourage patients to seek out expert care. Meaning see a person who specializes in treatment of colorectal cancer. So, a colorectal surgeon and a colorectal medical oncologist. I am a medical oncologist who specializes in treatment of patients with gastrointestinal cancer.

These sorts of specialists are typically found at high-volume cancer centers. Look for National Cancer Institute-designated comprehensive cancer centers. That designation implies very high quality of care and that there’s a lot of basic science research, clinical research, and what we call translational research. Like trying to bring lab discoveries to the bedside. I would encourage that for everybody. Of course, not everyone lives near such a center, but what we’ve learned through the pandemic is that we can use telemedicine far more than we ever did before.

We do a lot of virtual visits with patients who may live many hours away. I think it’s important, even if you have one visit for a second opinion, a treatment plan, that you could then receive that treatment with the local oncologist. I think that’s very helpful, and I would encourage everyone to seek out an expert opinion.

Also, I think it’s very important to seek out as much support, because this is a major diagnosis and a lot to go through. There is a lot of support out there that people may not be aware of besides, of course, family and friends. There are excellent patient advocacy groups and groups like your organization, trying to bring information to patients. Patients can ask their doctor or nurse about what’s local in terms of support groups, but there are also large internet presences by patient advocacy organizations. They are giving people high-quality, evidenced-based recommendations, advice.

People get to learn from other peers who have gone through treatment. I can’t name them all, but just for example, like the Colon Town and Colorectal Cancer Alliance. I believe just launching today is My Bluem, B-L-U-E-M.org.

I happen to be executive board member of that, so full disclosure. But it’s an organization created by colorectal cancer survivors for patients to come to one website to access information about all of these different

organizations. There is a huge community out there for people who are diagnosed with colorectal cancer. The third piece of advice, I would just say when you’re looking for information, make sure it’s from a reliable source like these patient advocacy organizations. I tend to look myself for websites that end in .org, .gov, .edu, and also .net.

Our American Society of Clinical Oncologists organization is ASCO.net, where you can get great advice about cancers. Cancer.gov, cancer.org. Because the internet is full of suggestions which may not be based in good science.

It’s important to have a good source.

Katherine Banwell:

Good advice. Thank you for that.

What Should Be Considered When Choosing a Colon Cancer Treatment Approach?

What Should Be Considered When Choosing a Colon Cancer Treatment Approach? from Patient Empowerment Network on Vimeo.

Dr. Smitha Krishnamurthi, a colon cancer specialist from Cleveland Clinic, reviews considerations when choosing therapy, including staging and test results, as well as how clinical trials fit into treatment planning.

Dr. Smitha Krishnamurthi is a gastrointestinal medical oncologist at the Cleveland Clinic. Learn more about Dr. Krishnamurthi here.

See More From The Pro-Active Colon Cancer Patient Toolkit


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Newly Diagnosed With Colon Cancer? Key Advice From an Expert

Your Colon Cancer Care Colon Cancer Toolkit: Office Visit Planner

How Speaking Up Can Positively Impact Your Colon Cancer Care

Transcript:

Katherine Banwell:

What are the main factors you take into consideration before a treatment approach is decided on?

Dr. Krishnamurthi:

For treatment of anyone with colorectal cancer, most important, of course, is the stage because stage determines whether it’s surgery alone or do we need to use chemotherapy or radiation? Or if it’s metastatic, is it systemic treatment only? We also look at the biologic features of the cancer, which we’re learning more and more are very important.

For example, we want every patient to know their DNA mismatch repair status. This is basically, is the cancer missing a gene that repairs damage to DNA? Then if that’s true, then we say they are DNA mismatch repair deficient. Or another term is “high microsatellite instability.” Mismatch repair deficient or microsatellite instability high, or you might hear MSI high.

That’s very important that we test that on all patients with colorectal cancer because in the early stage setting, it’s important because this is a way to identify patients who may have Lynch syndrome, the most common type of inherited colorectal cancer.

And also it impairs their prognosis. We know these patients tend to have a better prognosis. For example, for stage 2, we wouldn’t even have a conversation about chemotherapy if we know the patient has abnormal DNA mismatch repair or is MSI high. Then for patients of metastatic disease, it’s very important to know this upfront because those patients do better with immunotherapy as their first treatment.

So, we want to see those results for each patient. Then for our patients with metastatic cancer, we also need to see some other genetic mutations such as RAS, KRAS and NRAS gene mutations, because that affects what treatments we use.

Also, BRAF gene mutations are very important because of the particular regiment we use for treatment of that type of cancer.

We’re looking at the extent of the disease, what are the molecular features, and then also, of very importantly, what can the patient tolerate? What are the patient’s goals? We have a discussion about side effects and help them make the best choice for themselves.

Katherine Banwell:

Where do clinical trials fit in?

Dr. Krishnamurthi:

That’s an excellent question because clinical trials actually could be appropriate at any step along this pathway.

There are clinical trials that may be looking at tests to diagnose cancer better or detect it earlier.

There are treatment trials where they may be looking at standard treatment versus something investigational or standard plus investigational. Those sorts of treatment trials may be very interesting as the initial treatment or they could be used when a person has gone through all the standard treatments. Then there’s nothing left to do but try investigational. There are also studies that are looking at supportive care – a new treatment for nausea, for example. There are studies that are looking at the biologic factors of the cancer. Maybe asking a person to donate blood or give permission to use their tumor sample. By participation in these studies, people who volunteer for that are being so generous with their time and their lives.

But that’s how the field advances, especially for treatment trials. This is a way to access cutting edge treatments because the study is being done because the drug looks promising.

I think it’s very important to ask about clinical trials from the beginning and every time there’s a decision point made in the treatment.

How Is Colon Cancer Treated?

How Is Colon Cancer Treated? from Patient Empowerment Network on Vimeo.

Dr. Smitha Krishnamurthi, a colon cancer specialist from Cleveland Clinic, shares an overview of colon cancer treatment and which approaches are used for each stage for optimal patient outcomes.

Dr. Smitha Krishnamurthi is a gastrointestinal medical oncologist at the Cleveland Clinic. Learn more about Dr. Krishnamurthi here.

See More From The Pro-Active Colon Cancer Patient Toolkit


Related Resources:


Transcript:

Katherine Banwell:

Can you provide us with an overview of how colon cancer is treated?

Dr. Krishnamurthi:

Yes. Colon cancer is treated based on the stage. It’s a disease that, for the vast majority of patients, is only cured with surgery.

If it can be surgically resected, that’s how this disease is cured. So, it’s very important that we do all we can to maximize early detection because it’s a highly curable cancer when it’s caught early. For early-stage colon cancer, patients are treated with surgery. So, stages 1, 2, and 3.

If it’s rectal cancer, we do some treatment before surgery. We give some chemotherapy and radiation for stages 2 and 3 beforehand to maximally shrink down the tumor to enable the surgeon to take the tumor out of the pelvis with normal tissue all around, like negative margins. Rectal cancer tends to be more complicated surgery because of its location in the pelvis.

So, it’s a little bit different from colon cancer in that we do that chemo radiation and chemotherapy up front. Whereas, for colon cancer, patients who have early-stage disease have surgery. And then, if it’s just stage 1, and this is true for rectal also, they’re done.

Excellent prognosis and go on to surveillance.

But if it’s a stage 2, then in colon cancer we have a discussion about chemotherapy afterwards because that could increase the cure rate for some patients. But for stage 3, we absolutely want to offer chemotherapy to our patients with colon cancer because of this very long, proven track record that chemotherapy can increase the cure rate for stage 3 patients, so when it’s gone to lymph nodes. Then if the disease is metastatic, meaning it’s spread to other distant organs like liver or lung, chemotherapy is the mainstay of treatment, generally speaking.

But there are subsets of patients who benefit from surgery. So, if the cancer is metastasized to just the liver or the lung or both organs, but in limited fashion, there is a track record for patients being cured with surgery.

We always are considering that when we have patients with metastatic disease. My first thought is, is this cancer potentially curable? Then we go from there. In some cases, it’s clear that it’s not curable; it’s widely metastatic. Then there’s no point in subjecting a person to surgery and we know that chemotherapy or drug therapy would be the mainstay of treatment.

What Are the Stages of Colon Cancer

What Are the Stages of Colon Cancer from Patient Empowerment Network on Vimeo.

Colon cancer specialist, Dr. Smitha Krishnamurthi of Cleveland Clinic, provides an overview of the stages of colon cancer and how these stages are determined.

Dr. Smitha Krishnamurthi is a gastrointestinal medical oncologist at the Cleveland Clinic. Learn more about Dr. Krishnamurthi here.

See More From The Pro-Active Colon Cancer Patient Toolkit


Related Resources:

How Is Colon Cancer Treated?


Transcript:

Katherine Banwell:

Let’s start with a basic question. What are the stages of colon cancer?

Dr. Krishnamurthi:

Colon cancer is categorized in four stages – stage 1, 2, 3, 4. This takes into account the tumor itself, how thick it is. These tumors start on the inside of the colon, like as a polyp. Then they can grow through the colon wall. The tumor thickness and has it spread to any of the lymph nodes? and has it spread further to a distant organ like liver or lungs?

That’s a tumor node metastasis. Considerations that go into the staging. Stage 1 colon cancer or colorectal cancer would be a very shallow tumor, maybe just in a polyp and hasn’t spread to any nodes or anywhere else. Stage 2 is when the tumor is thicker. It may be involving the full thickness of the colon or rectum but has not spread to any nearby lymph nodes. Stage 3 is when the cancer has spread to regional or nearby lymph nodes. Stage 4 is when it’s metastatic or it’s spread to another organ.

Katherine:

Okay. Thank you.

How Can BIPOC Prostate Cancer Patients Protect Themselves Against Care Inequities?

How Can BIPOC Prostate Cancer Patients Protect Themselves Against Care Inequities? from Patient Empowerment Network on Vimeo

How can BIPOC prostate cancer patients help protect themselves against care inequities? Host Dr. Nicole Rochester and Dr. Yaw Nyame share their perspectives about factors that work against equitable care for some BIPOC patients – and how patients and providers can work toward improving care for better health outcomes.

See More From Best Prostate Cancer Care No Matter Where You Live


Related Resources:

How Can Prostate Cancer Patients and Providers Help Ensure Quality Care?


Transcript:

Dr. Nicole Rochester: 

We know that there are as with every other type of cancer and every other disease, there are significant health disparities with BIPOC patients. And so, Dr. Nyame, I’d love for you to talk about specifically with prostate cancer, some of the disparities that you see in your practice and in your research, and then what are some things that patients of color can do to protect themselves from these inequities? 

Dr. Nyame: 

This is a very important topic for me, it’s something that I am very passionate about, and as Dr. Grivas alluded to, I am doing a lot of research on, and I think the statistics are so grey. Black men are 80 percent more likely to be diagnosed with prostate cancer. So the average man in the United States has a one and nine lifetime risk of being diagnosed with prostate cancer, that’s probably one in six or one in seven Black men. Black men are twice as likely to die from prostate cancer compared to men of other races and ethnicities in the United States, and a lot of this is driven by the social milieu and factors that we’ve talked about today. What troubles me is when we talk about these statistics, I fear that that in of itself is crippling for some Black men, “If I have this diagnosis, and I’m not going to do well. Why should I do anything?” And I can tell you that the literature and all the research that we do, and it gets refreshed every 10 years or so, someone will do the study and it shows that if we have Black men and men of other races or white men, and we give them the same treatment for the same level of disease, that the outcomes are actually very similar. And a better way to state that for me is if you’re diagnosed early and you get the treatment that you should get irrespective of your race, it seems like outcomes can be quite good. 

And so, a lot of what we see with regards to prostate cancer inequities are driven by lower treatment rates and probably an impact of lower quality care. And when I say that, what does that mean? Well, do you get your care at places like the Seattle Cancer Care Alliance or the Cleveland Clinic, or Johns Hopkins or MD Anderson, where you have providers who are expert and do a lot of prostate cancer care, or are you being seen by someone in the community who I guarantee is an excellent clinician, but doesn’t have the same resources and the same expertise, in the sense of being focused on one disease process or one set of cancers? For instance, we are genitourinary cancer specialists, a fancy term for being cancer doctors of the plumbing system. But because that’s all we focus on, we know a lot about the process, we know what works, and we know what the standards of care. So, I think when you can get the right treatment at the right time, and you can get it from teams that are really specialized in this, that our outcomes are going to not care about what your self-defined race is when you check the box. 

The problem is, how do we get…how do we close that gap that exists currently that doesn’t allow people to get that care, and I think we’ve talked about rurality, so I think…I grew up in Oklahoma, and I could see that if you are in the sticks in Oklahoma and you’re not near a cancer center, like something down in Dallas, that your care might be impacted, but…especially if you have to travel a lot and it’s expensive. But we have major U.S. cities like Los Angeles where you may share a ZIP code with a millionaire but use very different health services. So, it’s not always a reflection of how far you have to travel, but it also is factors about how welcoming institutions that provide high quality care can feel for populations like our BIPOC populations who sometimes have been the subject of medical experimentation and lower quality care sometimes because they might not get shuttled to the same services historically. And I think we have a lot to undo to rebuild the trust that is required to have Black men not be fearful of seeking care from us, but be trusting.