Tag Archive for: comorbidities

Which Factors Impact Advanced Prostate Cancer Treatment Decisions?

Which Factors Impact Advanced Prostate Cancer Treatment Decisions? from Patient Empowerment Network on Vimeo.

Once treatment goals are defined, what else goes into making an advanced prostate cancer treatment decision? Dr. Atish Choudhury reviews factors that affect options.

Dr. Atish Choudhury is the Co-Director of the Prostate Cancer Center at Dana-Farber/Brigham & Women’s Cancer Center.
Learn more about Dr. Choudhury here.

See More from Engage Prostate Cancer

Related Resources

Why Should Prostate Cancer Patients Partner in Care Decisions?

Why Should Prostate Cancer Patients Partner in Care Decisions?

Who Are the Members of a Prostate Cancer Care Team?

Who Are the Members of a Prostate Cancer Care Team?

An Expert Debunks Advanced Prostate Cancer Myths

An Expert Debunks Advanced Prostate Cancer Myths


Transcript:

Katherine:

Let’s start by understanding the goals of treatment. What are the goals of advanced stage prostate cancer? 

Dr. Choudhury: 

So, in general, the goal of treating any cancer is to a live a long, happy, healthy life with limited quality of life troubles from the cancer itself or its treatments. And so, for localized prostate cancer, that generally means treating with curative intent – that we give radiation or surgery, potentially in combination with hormonal treatments so that the cancer is taken care of and people can be cured and not need further treatments moving forward at all. 

And there are situations, even in fairly advanced cases, where that’s a reasonable and accomplishable goal. And there are other situations that we might not be able to cure the cancer completely, but the treatments can be quite effective at keeping it under control and keep people with a very good quality of life so that prostate cancer is not a day-to-day burden for them and that they can survive with cancer for years, and years, and years.   

Katherine:

What do you typically consider when determining the best treatment approach or option for a patient? 

Dr. Choudhury:

So, the starting point and the ending point is the patient themselves. And so, “the patient” means “What is their age? What is their fitness level? What are their activities? What’s the overall life expectancy? What are there other medical issues?” And then, we consider the cancer – “What is the stage? What is the grade? Where has it spread to, if it’s spread?” 

And then, we try to incorporate all of those pieces with data – with clinical trials that have already been reported – and we have a lot of data in prostate cancer from patients who’ve participated in clinical trials, often randomized to one approach versus another, that gives us a sense of “What are the approaches that really benefit patients in terms of increasing likelihood of cure or prolonging the survival?” 

And so, once we incorporate all of those things, we can come up with some treatment suggestions, and then patient preference on those suggestions obviously plays a very important role. But sometimes, we start down a line, and the patient is having troublesome side effects or it’s not working as well as we’d really hoped, and it’s important to be adaptive and to change things if things are not going down a route that we’d really hoped. So, that’s an ongoing conversation. It’s not that you make a treatment plan at the first visit and that’s the plan that’s stuck with throughout the whole course of things. 

It’s a conversation at every visit on how things are going in terms of how the patients are doing and how the cancer is responding. And then, again, try to manage side effects as well as we can and adjust things if we need to along the way – and maybe switch to something that’s potentially going to be better tolerated or more effective, depending on what we see. 

Katherine:

Right. It sounds like there are many factors to weigh when making this decision.  

Does Acute Myeloid Leukemia Prognosis Vary by Age?

Does Acute Myeloid Leukemia Prognosis Vary by Age? from Patient Empowerment Network on Vimeo.

With acute myeloid leukemia (AML), does prognosis change according to age? Watch as expert Dr. Catherine Lai explains factors that can impact AML treatment options and methods for optimal patient care.

See More from Best AML Care No Matter Where You Live

Related Resources:

Empowered AML Patient: Ask the AML Expert

Empowered AML Patient: Ask the AML Expert 

Understanding High-Risk Acute Myeloid Leukemia Treatment Advances and Options

Understanding High-Risk Acute Myeloid Leukemia Treatment Advances and Options 

Advice for Acute Myeloid Leukemia Patients Seeking a Clinical Trial

Advice for Acute Myeloid Leukemia Patients Seeking a Clinical Trial 


Transcript:

Sasha Tanori:

Does prognosis of AML vary by age?

Dr. Catherine Lai:

So, yes and no. So let me answer that in two steps, so it does in the sense that older patients are more likely to have more comorbidities, so more medical problems, and so therefore have a higher likelihood of having complications, and also as patients get older, they acquire more mutations and more abnormality, so those molecular abnormalities, and so therefore, older patients then are become more challenging to treat as well. What I would say though, is that we typically risk-stratify based on molecular factors, so the different mutation than somebody has and the age and the comorbidities don’t necessarily play into that role of stratification, so for example, whether or not you’re receiving a transplant or not…age is a factor, if you’re kind of in that little risk category, the intermediate risk category, the other thing I would say is that for young patients, they are able to tolerate because many don’t have medical problems, so they are able to tolerate treatment better, so when I’m talking about numbers and likelihood of response and overall survival, those…all those mediums assume that somebody is in their mid-60s, and so I adjust the numbers because for younger patients that those numbers are likely higher…

Because they’re less likely to have complications.

Key Considerations When Making Prostate Cancer Treatment Decisions

Key Considerations When Making Prostate Cancer Treatment Decisions from Patient Empowerment Network on Vimeo.

What considerations are vital when making prostate cancer treatment decisions? Expert Dr. Tomasz Beer shares important factors that impact advanced prostate cancer care.

Dr. Tomasz Beer is Deputy Director at OHSU Knight Cancer Institute. Learn more here: https://www.ohsu.edu/people/tomasz-m-beer-md-facp.

See More From Engage Prostate Cancer

Related Resources

Which Prostate Cancer Treatment Is Right for You? What You Need to Know

Guide: Which Prostate Cancer Treatment Is Right for You? What You Need to Know

Engage Prostate Cancer Resource Guide

Engage Prostate Cancer Resource Guide

How Can You Access Personalized Prostate Cancer Treatment

How Can You Access Personalized Prostate Cancer Treatment? Resource Guide


Transcript:

Katherine:          

What are the considerations when choosing treatment for advanced prostate cancer?

Dr. Beer:                     

Well, here, the considerations in advanced prostate cancer are first and foremost, what is the best treatment for this particular individual, right?

That’s what we want to do, and by the best treatment, I mean most effective with the fewest side effects, protecting their quality of life. But that’s an oversimplification. In reality, to arrive at what the best treatment is, we need to really understand quite a bit about the patient’s cancer. Sometimes it’s mutational status, as we discussed earlier, but also, the way it’s presenting, how aggressively it’s growing, is it involving the liver or lungs, or is it only in the bones, is it fast, is it slow.

And then the other thing that is extremely important is the patient’s health, other medical conditions. Some treatments are really more difficult to give when somebody has cardiovascular disease, or diabetes, or nerve damage, or other causes preexisting to the cancer treatment.

So, those kinds of things which we call comorbidities in the medical arena are really important in refining the risk-benefit ratio for each treatment. And finally, and critically, what prior treatments patients have received, that’s a major consideration. We obviously wouldn’t be using the same treatments again in many patients. There are exceptions to that, but for the most part, if a treatment’s failed once, it’s not likely to be of great benefit.

So, we integrate the cancer presentation, perhaps genomics in some situations, patient-specific health conditions, patient’s prior treatments, and then of course, patient’s values and personal priorities and what’s most important to them. And from all of that information, we take a look at the available portfolio and suggest one or two options, which we as physicians, based on our experience, expertise, and the knowledge of the literature, believe that fit most closely and are most likely to be successful.

Myeloma Treatment Decisions: What Should Be Considered?

Myeloma Treatment Decisions: What Should Be Considered? from Patient Empowerment Network on Vimeo.

When deciding on a myeloma treatment, what factors affect your choice? Dr. Joshua Richter shares key considerations, the patient role in making decisions, as well as key questions to ask about treatment

Dr. Joshua Richter is director of Multiple Myeloma at the Blavatnik Family – Chelsea Medical Center at Mount Sinai. He also serves as Assistant Professor of Medicine in The Tisch Cancer Institute, Division of Hematology and Medical Oncology. Learn more about Dr. Richter, here.

See More From Engage Myeloma


Related Programs:

Which Myeloma Patients Should Consider Stem Cell Transplant?

Myeloma Treatment: When Should a Clinical Trial Be Considered?

Is the COVID-19 Vaccine Safe for Myeloma Patients?


Transcript:

Katherine:

Dr. Richter, would you please start by introducing yourself?

Dr. Richter:

Sure, my name is Dr. Joshua Richter. I’m an Assistant Professor of Medicine at the Tisch Cancer Institute Icon School of Medicine at Mount Sinai and the Director of Myeloma at The Blavatnik Family Medical Center at Chelsea at Mount Sinai.

Katherine:

Great. Thank you. When making a treatment choice, what are three key considerations for myeloma patients?

Dr. Richter:

Absolutely. So, whenever we decide on treatment options, we consider three main topics: patient-related factors, disease-related factors, and treatment-related factors. So, patient-related factors are easy. How old or young are you? How fit or frail? Do you have any comorbidities, meaning other medical problems like heart disease or diabetes?

Disease-related factors are another important one. How aggressive is your disease? Is it rising up very quickly? Is it very slowly? Do you have something that we call extramedullary disease which means myeloma outside the bone marrow in the mass that we call a plasmacytoma? And that influences how we treat things.

And the last is treatment-related factors. What treatments have you, previously, had, how did you respond to them, and what side effects did you have?

If you developed a lot of neuropathy with one drug, we may not want to choose a drug that continues to have that type of side effect profile.

Katherine:

What’s the role as a patient in making treatment decisions?

Dr. Richter:

The role, from my standpoint of the patient, is honesty. You don’t get extra points for being in pain. I want to hear from you. I want you to tell me what your concerns are, short-term, long-term. I want you to tell me about little problems that you don’t – it’s not that you don’t want to bother your care team, we want to know.

Because something little may mean something big to us. So, all we want is for your well-being. And the better we keep those lines of communication open, the better.

Katherine:

Are there questions that patients should consider asking about their treatment plans?

Dr. Richter:

Absolutely. I think in a day and age where there’s so many different options, I think it’s always important to ask the care provider, what are the alternatives to this? Or why did you select this treatment for me? Because many times, there are alternative answers. So, in myeloma, there are a lot of options that may be good for someone. And the physician team may say we recommend this drug, and the patient may have trouble getting back and forth to clinic for logistical reasons. And there may be an all-oral alternative that if you don’t ask, we may not know that that’s going to be your preference. So, really that dialog is crucial.

CLL Clinical Trials Explained

CLL Clinical Trials Explained from Patient Empowerment Network on Vimeo

What are the phases of clinical trials in chronic lymphocytic leukemia (CLL), and what happens during each phase? Expert Dr. Anthony Mato explains the phases, criteria for trial selection, and addresses patient fears.

Dr. Anthony Mato is Director of the CLL Program at Memorial Sloan Kettering Cancer Center. Learn more here.

See More From The Pro-Active CLL Patient Toolkit


Related Resources

 

An Expert’s View on Promising CLL Approaches

Factors That Guide a CLL Treatment Decision

Is My CLL Treatment Working

Transcript:

Katherine:                  

For people who don’t understand how treatment approvals work, which would you give us an overview of the stages of clinical trials?

Dr. Mato:                   

Sure. I’m very involved in clinical trials at my center. There are different phases of clinical trials. And so, the way that I think about them would be – let’s focus on Phase I through III, because those are probably the most relevant ones for patients. The purpose of a Phase I trial is really to define the dose of the drug and confirm that it’s safe or not. We get very, very preliminary data about activity of the drug, but the major question that’s being asked is, “Is this drug safe?”

Phase II is – and I should also add that Phase I trials are relatively small. So, it’s a small number of patients where we’re trying to find the right dose. By the time we get to Phase II, we know the drug is likely safe. We have a lot of information about its side effect profile. We might have a hint that it’s active. And so, the purpose of a Phase II trial is to expand the size of the trial, have more patients recruited, get more information about safety but then get more information about activity.

Of course, there’s no comparator generally in a Phase II trial. So, it’s not like I’m asking this drug versus another drug. And the end of a Phase II trial, we know the drug is active, we know it’s safe. And if it appears to be active, we’re feeling confident that it may be better than a standard of care which leads to Phase III where the drug is compared directly in oftentimes what we call a randomized study to a standard of care.

So, the trial that I mentioned earlier, FCR versus FC would be a great example of a randomized, controlled trial where a new therapy would, in that case, the FCR, was compared to the old therapy, the FC.

In the more modern era, there have been several trials. I example I might mention is the RESONATE trial where ibrutinib was compared head-to-head to an antibody called ofatumumab. Patients who were enrolled were either randomized by a coin flip through a computer to one arm or the other. And then those arms are compared directly to help define a standard of care.

So, that’s kind of the basics of clinical trials, and at our center and many centers around the country, we participate in Phase I, II, and III trials trying to ask different questions that are important to our patients.

Katherine:                  

Well, speaking of patients, they’re very often fearful of participating in a clinical trial. What do you say to them to make them feel more comfortable with the idea?

Dr. Mato:                   

I mean, I think the most important thing to highlight is all of the standards of care that we’re using today, ibrutinib, acalabrutinib, idelalisib (Zydelig), duvelisib (Copiktra), venetoclax (Venclexta), these were all just drugs a few years ago that were studied in the context of clinical trials.

And so, our current standards of care are very new on the scene from clinical research. It’s very important to have a conversation with your doctor about the intent of a particular clinical trial. I think most patients are fearful of placebos or blinding where they don’t know what they’re getting, or it’s possible that they’re not getting any treatment at all.

In oncology and particularly CLL, the chances of a clinical trial having a placebo or blinding are very low. We very rarely ever participate in such studies. And so, that should provide reassurance to the patient that they know what they’re getting, they know they’re dose, their oncologist knows what they’re getting, and oftentimes, many clinical trials have mechanisms called crossover built into them. Meaning, that if you’re getting A versus B, and you get B, and it doesn’t work, you often have opportunity to cross over to A.

Clinical trials in CLL are the reason why there’s been so much innovation over the last several years, the reason why we can talk about six and seven approvals of drugs within half a decade.

And many of the drugs that we have at our centers will likely become standard of care in the near future. So, it gives us access to important drugs a little bit in advance of when they might be available for patients through FDA approval. So, it a lot of hope; it’s a lot of innovation. And the major message I would say to patients is don’t think of a clinical trial is for when all options have run out, but oftentimes there are great trial options that are aiming to improve the current standard of care in the frontline and also the relapsed/refractory settings.

Katherine:                  

What’s involved in patient participation in clinical trials?

Dr. Mato:                   

Well, the process is called informed consent, and so, if you’re interested in a clinical trial, you have a conversation with your oncologist to review the study, the schedule, the screening procedures. If you’re interested, you sign an informed consent and then begin a process of doing some testing, oftentimes scan, blood work, EKGs, bone marrow biopsy, to try to identify whether or not you’re a good candidate for the study.

Clinical trials are often more rigid than standard of care meaning you have to follow a strict schedule. You have to report everything, side effects, or successes related to the clinical trial. And oftentimes, a clinical trial is performed at the particular center that you signed the consent. And so, if you came to our center at MSK, odds are you would have to have treatment at our center in order to participate in that trial.

Once you’re enrolled on the trial, you’re on a strict schedule. You work with the physician and a research team, often a nurse directly who specializes in clinical trials to help ensure that you’re monitored appropriately and that the trial is successful for the patient.

An Expert’s View on Promising CLL Approaches

An Expert’s View on Promising CLL Approaches from Patient Empowerment Network on Vimeo.

As chronic lymphocytic leukemia (CLL) research continues to expand, new and promising treatment approaches have emerged. Dr. Anthony Mato shares information on developing therapies, including inhibitor, immunotherapy, and antibody options. 

Dr. Anthony Mato is Director of the CLL Program at Memorial Sloan Kettering Cancer Center. Learn more here.

See More From The Pro-Active CLL Patient Toolkit


Related Resources

 

Is My CLL Treatment Working

Factors That Guide a CLL Treatment Decision

CLL Clinical Trials Explained

Transcript:

Katherine:                  

Let’s get into developing research. Let’s get into developing research and what it can mean for patients. What new approaches are showing promise?

Dr. Mato:                   

Wow, that’s a loaded question, because there are so many possible answers. There are new versions of the current standards of care, different classes like BTK inhibitors or PI3K inhibitors which have the potential to be very active but better tolerated.

So, that’s one big group of new agents in development. There are several agents in development that appear to be effective in the setting of resistance to the current standards of care. There are classes of immunotherapies that allow us in different ways to use the immune system of the patient to fight cancer directly, so not necessarily targeting the cancer cell but targeting the immune system to make it do its job to filter out the cancer.

There are new antibodies in development. And that’s just a little slice of what’s in development for CLL and new combinations of course of the current standards of care which when put together could be even more effective. So –

Katherine:                  

What about – oh, go –

Dr. Mato:                   

Sorry. I was just going to add that so many different possibilities available that not every center can participate in all of these types of research, but it’s amazing for patients to know how many different new options are in development that maybe even better than the current approaches.

Katherine:                  

Right. What kind of side effects might be involved with the emerging treatments? What might people expect?

Dr. Mato:                   

That’s a hard question to answer, because the purpose of the clinical research is to help define the side effects associated with these newer drugs. And so, while we have a hint from early data or from Phase I data what a side effect profile might look like for a new drug, part of the consenting process is to help gather information not only about a drug’s activity but also about its side effect profile.

So, when we consent a patient, there is a little bit of an unknown about side effects, and we have sometimes very limited information that we can share about the activity. So, it’s not easy to just group these together and say these are the newest side effects to worry about. That’s really the purpose of the studies that I’m mentioning and the general idea of clinical research.

Katherine:                  

And that makes sense. How is research into the genetics of CLL providing a better understanding of how a patient’s individual disease may behave?

Dr. Mato:                   

Well, just a few years ago, the basic genetic studies for CLL included just a few chromosomal markers that we could easily or sometimes not so easily test. At our center, for example, and it’s not unique, we’ll be able to look at the over 400 different mutations associated with hematologic malignancies. The more information we get, the more we realize that although under the microscope a CLL cell may look like another CLL cell, biologically, they’re very different.

They’re driven by different genetic mutations, and knowledge of those pathways that are important for an individual CLL will oftentimes, will hopefully in the future guide how therapy is selected for patients.

Is My CLL Treatment Working?

Is My CLL Treatment Working?  from Patient Empowerment Network on Vimeo.

During chronic lymphocytic leukemia (CLL) treatment, specific blood tests and diagnostic measurements are examined to gauge a patient’s treatment response. Dr. Anthony Mato details the specific criteria that are assessed while monitoring a therapy. 

Dr. Anthony Mato is Director of the CLL Program at Memorial Sloan Kettering Cancer Center. Learn more here.

See More From The Pro-Active CLL Patient Toolkit


Related Resources

 

An Expert’s View on Promising CLL Approaches

Factors That Guide a CLL Treatment Decision

CLL Clinical Trials Explained

Transcript:

Katherine:                  

How do you monitor to see if a treatment is working, and what if the patient doesn’t respond to any of the treatments?

Dr. Mato:                   

Yeah, so, we response criteria, and so, they’re largely very simple measures. We perform a physical examination before and after treatment to see if the lymph nodes and spleen are decreasing in size. We measure the white blood cell count to verify that it’s going down. We look for normal parameters of normal functioning bone marrow like improvement in the hemoglobin or the platelet count.

So, those are some of the measures we use, and we put them together. And of course, just asking a patient how do they feel, do they feel better, are the symptoms that were associated with the CLL improving, and if the answer is yes, that would be considered responding disease. We also sometimes do measures like CAT scans to measure internal masses or internal lymph nodes and a bone marrow biopsy to verify that all the CLL cells are gone.

So, that’s the basics of a response assessment, and we also venture now into a new territory called MRD, or minimal residual disease, where we’ll be able to look beyond the traditional response assessment. Sometimes, it measures at a measurement of one in a million cells to verify that there’s no evidence of CLL present. If a therapy’s not working, fortunately – well, first I’ll say that with the modern therapies that we’ve already mentioned, response rates exceeded 90 percent.

So, it very, very infrequent that we have a patient where we pick the appropriate therapy where it doesn’t work for them. But if one is not working, then we do have measurements of resistance, and we can try to tell why a therapy maybe not working and switch them to an alternate class. And oftentimes, that will solve the problem.

Katherine:                  

Dr. Mato, you mentioned the term MRD. What does that mean?

Dr. Mato:                   

It stands for minimal residual disease. That’s using technology like flow cytometry or PCR or sequencing to take a deep look in the bone marrow and the blood for the presence or absence of CLL.     

So, when I perform a bone marrow biopsy, a pathologist with their eyes might count one hundred cells. With MRD testing we could look at 10,000 or 100,000 or 1,000,000 cells to see if there’s any CLL present, much more than the human eye or the human brain could process.

Factors That Guide a CLL Treatment Decision

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

When making a chronic lymphocytic leukemia (CLL) treatment decision, several factors come into play. Dr. Anthony Mato explains how he partners with patients to find the best fit for their specific CLL.

Dr. Anthony Mato is Director of the CLL Program at Memorial Sloan Kettering Cancer Center. Learn more here.

See More From The Pro-Active CLL Patient Toolkit


Related Resources

 

An Expert’s View on Promising CLL Approaches

Is My CLL Treatment Working

CLL Clinical Trials Explained

Transcript:

Katherine:                  

So, with all of these options, how do you then decide which class might be right for an individual patient?

Dr. Mato:                   

Well, you think about the patient. You think about their medical history, their comorbidities, their preferences, and then you try to focus on their disease biology, their genetic factors, their molecular factors, and also what therapies they’ve had. So, if I had a patient who had ibrutinib (Imbruvica) previously, I’m not going to give them acalabrutinib if they were resistant, for example. So, it’s not just one thing. It’s multiple things that have to be taken into account in order to make a decision.

And, of course, for me as an oncologist, the hardest part is that there have not been many trials comparing the newest therapies to one another. So, I can’t tell you what’s better ibrutinib or acalabrutinib (Calquence) by a head-to-head comparison. I can’t tell you whether you should start with ibrutinib before venetoclax (Venclexta) or venetoclax before ibrutinib not because we’re not very interested in having those studies performed. But they have not been performed at this point in time.

The only thing I can tell you based on prospective data from a head-to-head comparison is that we do have direct data comparing acalabrutinib which is a BTK inhibitor to idelalisib (Zydelig) in the relapsed/refractory setting. And by all measures, acalabrutinib was better tolerated and more effective. So, we have some very early head-to-head data but not as much as we need in order to make these decisions for patients.

Katherine:                  

How are side effects taken into consideration?

Dr. Mato:                   

Well, all of these drugs although they are targeted, and they’re oral, and they’re relatively easy compared to chemotherapy are not without side effects. And so, each of these classes have their own unique side effects. BTK inhibitors can be associated with increased bleeding risk or atrial fibrillation or infection. PI3K inhibitors can be associated with lung or liver or colon damage. BCL-2 inhibitors might be associated with lowering of the blood counts and infection risk or something called tumor lysis syndrome.

So, we try to, if you had a side effect to one, not pick a drug with the exact same side effect profile, for example. And we also think about medical history for patients. So, if I had a patient who was on blood thinners and has poorly controlled atrial arrhythmia like AFib, I might not start them on a BTK inhibitor. If I patient who has active Crohn’s disease or ulcerative colitis that’s poorly controlled, I might not start them on a PI3K inhibitor. And if I have a patient who’s near dialysis because of chronic kidney disease, and I’m worried about further tumor lysis syndrome, I might not start them on a BCL-2 inhibitor.

So, you kind of weigh a patient’s medical history, their prior therapies, and their response and toxicities, and then make a decision on what’s the best fit for patients.

Katherine:                  

Well, what kind of testing is involved to make sure you have the best approach?

Dr. Mato:                   

Well, there are several tests that we think about using or we do use, and they’re mostly genetic and prognostic tests. And so, what we like to do is look at the CLL cells beyond looking at them under a microscope to try to identify the genetic markers that drive the biology of CLL. So, for example, if I have a patient who has deletion 17p which is one of the more feared chromosome abnormalities, I know right off the bat chemotherapy’s not a good fit for that patient. But I can do quite well with a BTK inhibitor like ibrutinib.