Tag Archive for: comorbidities

Personalized Lung Cancer Treatment | Key Factors to Consider

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Personalized Lung Cancer Treatment | Key Factors to Consider from Patient Empowerment Network on Vimeo.

How is lung cancer therapy personalized? Dr. Erin Schenk, a lung cancer specialist and researcher, reviews important factors and considerations that affect therapy choices, including lifestyle and patient preference.

Dr. Erin Schenk is a medical oncologist, lung cancer researcher, and assistant professor in the division of medical oncology at the University of Colorado Anschutz Medical Center. Learn more about Dr. Schenk.

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Transcript:

Katherine Banwell:

Personalizing therapy involves taking into account a number of patient factors. What should be considered when deciding on a treatment regimen for a given patient?   

Dr. Erin Schenk:

Uh-huh, yes. That’s a great question and one that is really important in formulating a treatment plan. So, some patients because of their health status, for example, aren’t able to undergo surgery, and that happens. And so, occasionally sort of their health status maybe their lungs don’t work as well as they used to or the heart doesn’t pump as well as it used to. 

You know, those sorts of health concerns can help us tailor and personalize treatments to what would be the most – the safest but also the most effective approach. Occasionally patients have another long-term chronic disease where using immunotherapy might be more dangerous than helpful because they’re sometimes autoimmune diseases.  

Especially ones that affect the brain, so for example multiple sclerosis can be one of those or disease that affect the lungs, you know, interstitial lung diseases. Those would put a patient at great risk of receiving immunotherapy, but outside of the health status, it’s also important I think to talk about what your preferences are as a patient as well.  

Because sometimes we will come to you and say, “Here are these multiple different choices and what’s important to you or maybe what you’re worried about or what you’re concerned about are considerations that we want to hear about and understand so that we can talk you through the process and help make some of these decisions.” You know, for example, if you’re receiving chemotherapy plus radiation together for your cancer care that can be a huge time commitment.   

What I mean by that is when patients get radiation in certain circumstances, that can be once a day every day, Monday through Friday for six weeks at a time and sometimes patients have challenges with transportation. Or sometimes they have you know, challenges balancing a job or childcare or other things like that. So, these are all part of the – just part of bringing it all together and putting together a treatment plan that makes sense for what we understand about the lung cancer itself, but also what we understand about you as our patient. 

You know, how can we make changes or make suggestions that would best fit for you and your needs?  

Katherine Banwell:

When should patients consider a second opinion or even consulting a specialist? 

Dr. Erin Schenk:

I think any time it’s appropriate. We – at our institution, we’re one of the main lung cancer centers that – you know, within several hundred miles, so we frequently see patients and sometimes it’s just to check in and say you know, the patient says, “Here’s what my team has started me on. You know, what do you think should be the next approach?” and we talk about that, but really anytime I think is appropriate for reaching out for another set of eyes to look at things. I would say perhaps some of those most critical times would be prior to treatment starts especially if – yeah, I would say prior to starting a treatment with that new diagnosis.  

That would be a really critical time because often again, sometimes once we start down a treatment path, we’re in some ways we’re committed, but if that maybe isn’t the optimal treatment path based on, you know, the tumor and the biomarkers and the patient preference starting on that less optimal treatment path could potentially hurt patients in the long run. So, I would say at – you know, potentially at diagnosis when a treatment course is recommended and then if there is a need to change treatments.  

So, for example, especially in the metastatic setting there are certain therapies widely available. People are very familiar with them, can start them no problem, but when those treatments stop being beneficial that might be a time to also meet with a specialist or go to a lung cancer center of excellence to get their opinions on what to do next.  

AML Treatment Decisions | Understanding Factors That Impact Your Options

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AML Treatment Decisions | Understanding Factors That Impact Your Options from Patient Empowerment Network on Vimeo.

An acute myeloid leukemia (AML) diagnosis can be different for each individual patient, so how is a treatment approach determined? AML specialist Dr. Jacqueline Garcia provides an overview of factors taken into consideration when choosing therapy, including age, overall health, and the patient’s preference. 

Dr. Jacqueline Garcia is an oncologist and AML researcher at the Dana-Farber Cancer Institute. Learn more about Dr. Garcia.

See More from Thrive AML

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Transcript:

Katherine Banwell:

With all the treatment options available, how do you decide who gets what? Tell us what is considered when choosing treatment for a patient. 

Dr. Jacqueline Garcia:

When I – this is a complicated question, because it’s not like you follow any particular algorithm. But when I meet a patient, I make a decision on what’s important to the patient and what’s  their goal. If I know – I need to understand their overall health to get a sense of are there ongoing competing risk factors that are active and more likely to impede with response, ability to deliver chemo, ability to get to transplant, something that tells me that’s not a possibility, or is their age too advanced – meaning greater than 75 – where we know that some of the treatments are not safe to deliver in that setting?   

So, I take a look at a patient’s overall health and age to make a decision. I take a look at bone marrow biopsy and lab findings to understand the flavor of their leukemia, from chromosomes to mutations. And because I am familiar with the data to give me a sense of what’s safe, what’s tolerable, and importantly what types of diseases, or subtypes of AML, would respond to one therapy over another, that’s how I formulate a recommendation.  

And based on all of that, all together, I’ll talk to them about treating the AML in steps. The first step is getting them into a remission, which can be done regardless of therapy type. That means to get their bone marrow under control, blood counts to recover. The second step, which is a more involved conversation that I often give a little bit of a hint of, but I go into greater detail over time, because we will see each other quite a lot, whether in the hospital or in clinic, is how to keep them in remission.  

And that’s where details about things like transplant come into play. I do my best to not overwhelm them, because when a patient hears the word transplant – and that’s often what they hear from family and friends because that’s what you can Google – they don’t know that there are many things, or many weeks of therapy, that have to happen in advance of transplant even being considered or happening. And transplant can’t even happen until someone’s in remission.  

But that is always on the forefront of a leukemia doctor’s mind, “Can I bring this patient to a transplantation? How successful will I be and what else do I need to give them to get them there sooner, safer, with a deeper response?” So, that way transplant could be successful. Transplant, by the way, is when we give a patient someone else’s stem cells that match their HLA typing, or their white blood cell signature.  

And it helps us to use someone else’s immune system to completely irradicate any microscopic leftover leukemia in a patient. But that is only successful when patients have good disease control or remissions. And that is only also successful if we have a donor for the patient, both of which  require at least several weeks to a couple of months of therapy. But that process is always initiated and ongoing in the background. And so, we often do this in piecemeal, because getting a diagnosis is already overwhelming. Learning about treatment is overwhelming.  

Learning about the frequency of labs, transfusions, being hospitalized, and then details about what a transplant would entail can be also overwhelming. But a lot of family and friends like to ask, because they feel like that is one way they might be able to help a patient. So, I know that they often eagerly ask the patient, “Well, what about this? How can I help?”  

Katherine Banwell:

Right. I can imagine that patient preference is also considered. But what kind of questions should patients ask about their treatment regimen?  

Dr. Jacqueline Garcia:

I always tell patients that I care very much about things like travel, hotels, all that jazz. But I always tell them let’s first talk about their health, what treatment I would recommend based on the available options and what their disease would mostly respond to, because I want it to be successful. And I always tell them let’s reserve questions on how it’s going to be done for last. I call that the logistics. I will never bring up or recommend something that could never be possible. But that being said, I try not to let the commute determine the decision.  

Whether or not there needs to be a hospitalization versus a hotel stay. I always consider then the background, but that financial decision should not drive the best treatment choice for a patient. Very fortunately, we’re in a country where patients have the ability – often, not always – to seek second opinions or to travel to academic centers.  

And because AML is an emergent or life-threatening disease, many insurance providers allow patients to come up to a big center to be treated, which I think is more than appropriate. So, we get into details of logistics last, because that’s the one thing that we can often overcome by providing additional resources and support. In terms of patient preference, if that’s what you mean with that, I would say I leave logistics to last, but we always consider and we do our best to accommodate.  

And that might be where we inform them we will look into getting a local partner to help us with additional therapies after the first month or upon discharge. So, it totally depends on the scenario for a patient, whether or not they have a local provider and a local hospital that could accommodate acute leukemia. I always tell patients ideally you don’t want to go to a place that only sees this once per year. You want to go to a place where everyone has seen it multiple times, including the nurses on the floors.  

So, that way, when there’s a complication, everyone knows what to do. We don’t want any “surprises” when it’s really just run-of-the-mill standard stuff for us every day. In terms of what patients desire, we always keep that in the conversation of their level of support. Can they swallow pills? Are they able to cope with being in and out of the hospital? All that stuff gets considered, but I think if they hear about the plan, about what’s required, when my expectation would be for a response, when the frequency of trips to a big city would decrease, how I could get a local partner to help with some of the lab or transfusion burden.  

Many of those preferences that they thought they had diminished, because they recognize that we found a way to make it work.  

Katherine Banwell:

Dr. Garcia, you mentioned earlier the fact that some therapies can cause a lot of side effects, like nausea. And certainly, speaking up and telling your healthcare team how you’re feeling and what some of the symptoms and side effects are, that’s really essential. What is the impetus for someone to consider changing treatment if something is just absolutely not agreeing with them?  

Dr. Jacqueline Garcia:

So, there are many reasons to change a treatment. One is a patient doesn’t tolerate it. It depends on what the issue is. Is it something that’s serious, like a liver or enzyme abnormality that is very abnormal, or a new cardiac problem where it would warrant a change or a dose reduction? That makes sense. There is definitely – often, there’s a lot of guidance in the package inserts or within a clinical trial and how to manage that. But if patient has some intolerabilities that could be overcome with standard supportive care methods, I would make sure we’ve done that.   

So, I would make sure you give you medical team the chance to fix any nausea. We have so many great antinausea drugs. I would want to make sure – or if constipation or diarrhea. It’s often a GI issue that patients get really bothered by.  

I would try to delineate whether or not the side effect was really from the chemo or is from the leukemia that is not yet under control. Or is it another medical condition or a drug-drug interaction that was missed. So, I would do my best to make sure there wasn’t something that was fixable or something else that should be addressed. We otherwise would recommend changing therapy for an extreme intolerability if there was another equivalent better option. And if someone’s disease does not respond to treatment, then we would consider another therapy, too.  

Endometrial Cancer Treatment Decisions | Factors That Impact Your Options

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Endometrial Cancer Treatment Decisions | Factors That Impact Your Options from Patient Empowerment Network on Vimeo.

Endometrial cancer expert Dr. Emily Ko explains health considerations and other key factors that may impact options when determining an optimal treatment approach for each patient. 

Dr. Emily Ko is a gynecologic oncologist and Associate Professor of Obstetrics and Gynecology at the University of Pennsylvania. Learn more about Dr. Ko.
See More from Evolve Endometrial Cancer

 

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Transcript:

Katherine:

Dr. Ko, what goes into determining a treatment approach for an individual patient? Is there key testing that helps guide a patient’s prognosis and treatment options? 

Dr. Ko:

Absolutely. So, I think the key pieces of information come from several sources. First, we do take the whole patient into account, like baseline health, baseline function, meaning every day, how active are you? Are there limitations to your daily activities? Looking at baseline health conditions, what we call comorbidities. Are there other health conditions, like diabetes, heart conditions, lung condition, kidney conditions, that could really impact a patient’s overall health and well-being? That is always part of it, number one. 

Then, we look specific to the cancer details. So, from all the pathology information, biopsies, followed by a surgical staging procedure, what exact stage, what exact substage, and we might even look at other unique features. Was there cells that got into the lymph vessels, the lymph nodes? Are there other just features from a pathology standpoint that are important, like the – I talked about microsatellite status, microsatellite instable versus microsatellite stable. 

Those are all information we can gather from the tumor tissue itself. That then kind of tailors our therapy. And then, like I was saying, now we’re going into this molecular era where we can actually take that tumor tissue and even do more expanded testing on it. 

So, I think it’s worthwhile to talk to your provider and say, “Hey, would it be worthwhile to send my tumor out for expanded testing, whether it’s done at your institution, at a specialized lab, or whether it’s sent out to a company that does expanded testing?” Because then, they might be able to test for 500 different genetic signatures, a much more broad panel, but that might open the door for opportunities to say, “Hey, you actually do have a very unique signature, and maybe it is worth tailoring your therapy even further.” 

So, I think these are very important questions to have with your provider, and these pieces of information can help guide the prognosis. I think we’re always asking what does this mean long-term, and I think when we have all these individual pieces of information, we can then give guidance on that.   

Katherine:

I wanted to get your point of view on why is it important for patients to engage in their care and their treatment decisions?  

Dr. Ko:

Right. I think that it is so important. Medical treatments, I think, do work the best for the patient when the patient is truly an active participant, and what I mean by that is I think we can really understand the patient if there’s a conversation, there’s a mutual discussion, and I think every patient has unique circumstances, has unique goals, has…whether it’s just the daily whatever responsibilities, or just either health or non-health concerns that they have, we want to be able to find a treatment that fits the patient, and we realize that one treatment doesn’t fit all. 

And so, the more, I think, that there is this mutual discussion, mutual understanding, then there’s a mutual decision treatment plan that is made, and there’s the more ability to modify that plan when – if you realize, oh, maybe we can tailor it, maybe we try one thing, and maybe we realize we got to change a little bit. 

And, I think that with a cancer condition, it is a journey. It is not just a one-time thing. It really is a journey, and I think that the more a patient can participate throughout that journey, I think the better the outcomes for the patient, and honestly, the better the treatment course will be for everyone participating.  

Katherine:

Why should a patient consider finding an endometrial cancer specialist? What are the benefits? 

Dr. Ko:

So, I think naturally, an endometrial cancer specialist is a provider who spends more time thinking about the disease, reading about it, looking at what’s the newest research studies that are coming out, what are the available clinical trials here, locally, regionally, or nationally, what are other support services available for the patient in the space. 

And, of course, probably the folks that do the most surgeries gear towards endometrial cancer patients, and so, I think just working in that space naturally then brings more resources and more opportunity for the patient to kind of really know what’s out there, what is the newest, and I think that really benefits the patient. 

Considerations That Help Guide Breast Cancer Treatment Decisions

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

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

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

See More from Thrive Breast Cancer

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Transcript:

Katherine:

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

Dr. Waks:

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

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

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

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

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

Katherine:

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

Dr. Ramaswamy:

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

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

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

What Factors Affect Myeloma Treatment Decisions?

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What Factors Affect Myeloma Treatment Decisions? from Patient Empowerment Network on Vimeo.

Myeloma treatment decisions can vary by patient. Expert Dr. Benjamin Derman reviews factors that may guide induction therapy choices, treatment classes currently available, and strategies for managing common side effects.

Dr. Benjamin Derman is a hematologist and oncologist specializing in multiple myeloma at the University of Chicago Medicine Comprehensive Cancer Center. Learn more about Dr. Derman.

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Transcript:

Katherine:

There are a lot of available therapies for myeloma. And I’m wondering what factors might impact treatment decisions. You did mention comorbidities. But what other factors are there?   

Dr. Derman:

Sure. And I think in part, it depends on if we’re talking about induction therapy or in the relapsed refractory setting. Let’s focus on induction therapy, right?  

So, there are some drugs that we’re typically going to employ pretty much universally. For those who are inclined to use that CD38 monoclonal antibody that I mentioned, it pretty much plays well with patients of all walks of life. So, that’s one where I feel really comfortable regardless.  

Lenalidomide is a drug that we don’t necessarily know from the get-go if there’s going to be a patient that’s not going to tolerate it well.   

We might reduce doses up front. But for the most part, that’s another drug that we’re typically going to use. I would say the one exception is for patients who have a simultaneous diagnosis of amyloidosis. And we know that in amyloidosis, lenalidomide may not be as well-tolerated.  

But actually, one of the key decisions that I’m often making in clinic myself is around that drug class that I mentioned earlier called proteasome inhibitors. And I mentioned two different drugs. There’s bortezomib and carfilzomib. And they actually come with very different side effects that I think are important to mention.  

Bortezomib is one that is typically associated with a high rate of numbness and tingling, what we call neuropathy in the fingers and toes. And about 75 percent of patients have been reported in the trials to get this. And most of it is what we call lower grade. But I’m not in the patient’s body, and I don’t know what that – what even a grade 1, which would be the lowest grade, really feels like. And if I have a mechanic, somebody who types for a living, a surgeon, somebody who uses their hands or their or rely on their feet for their day-to-day, that’s a scary prospect, right?  

The flip side is this drug, carfilzomib (Kyprolis), is one that does not really cause nearly as much neuropathy, but has been associated with cardiac effects. Heart issues. And so, that can scare people, right? Heart’s important I hear. So, we have to be really careful in how we pick these therapies and talk about it with patients.   

Does Prostate Cancer Hormone Therapy Cause Cognitive Issues?

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Does Prostate Cancer Hormone Therapy Cause Cognitive Issues? from Patient Empowerment Network on Vimeo. 

Could hormone therapy for prostate cancer lead to cognitive issues? Expert Dr. Tanya Dorff discusses whether there’s a link and explains which treatments may be helpful for cognitive issues.

Dr. Tanya Dorff is Associate Professor in the Department of Medical Oncology & Therapeutics Research at City of Hope. Learn more about Dr. Dorff.
 

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Transcript:

Katherine:

We received some audience questions prior to today’s webinar, and I’d like to go through some of them with you. Bob asks, “Does androgen deprivation therapy (ADT) cause cognitive issues?” 

Dr. Dorff:

So, androgen deprivation therapy is another way of saying hormone therapy. We’re lowering testosterone, which is an androgen, and the question about cognitive issues is a good one. If you look in the literature, it’s not been well-documented, and part of that is because our patients tend to have age and other comorbidities that can lead to changes in cognition happening at the same time as they’re being treated for prostate cancer, but also because the tools just haven’t been very good. 

The tests where we measure how your brain is working have traditionally not been very good. There are some better tools that have been developed, and we’re hoping to be able to – with some ongoing studies – better define are there cognitive changes? If so, how severe are they, how common are they, are they more common with one drug versus another? Very basic questions. 

I will say in my own practice, after 15 years of treating prostate cancer, I do believe that some patients experience cognitive changes during ADT. They can be mild, like taking longer to remember someone’s name or walking into a room and forgetting why you’re there, which, frankly, happens to all of us when we’re not having our best days, but obviously, I do see that a little bit more with prostate cancer patients who are receiving hormonal therapy.  

For some of my really high-functioning patients, it can be helpful to use a drug that treats attention because some of the cognitive dysfunction actually ends up being an issue with attention. So, we use drugs like methylphenidate (Ritalin) or dextroamphetamine mixed salts (Adderall) to support patients who need to be really focused, and I’ve had many patients tell me that that has made a huge difference for them, so it’s not going to solve the overall changes that may happen in the brain on the basis of the hormonal deprivation, which we know happens from animal models, but it can help in the short term so that men can continue to function at a high cognitive level, despite ADT, when needed. 

What Promising AML Treatments Are Available for Newly Diagnosed Patients?

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What Promising AML Treatments Are Available for Newly Diagnosed Patients? from Patient Empowerment Network on Vimeo.

What do newly diagnosed acute myeloid leukemia (AML) patients have for promising treatment options? Dr. Naval Daver from the University of Texas MD Anderson Cancer Center discusses progress in available treatments. Learn about therapies determined by key factors.

[ACT]IVATION TIP from Dr. Daver: “It’s very important to really consider all the available treatment options and if needed to seek consultation with an expert or academic center to get the most up-to-date treatments available for AML.“

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Transcript: 

Art:

Dr. Daver, for newly diagnosed AML patients, what are the latest and most promising available therapies?

Dr. Daver:

For newly diagnosed AML at this time, the most promising agents include targeted therapies and BCL-2 inhibitor treatments, these are non-chemotherapeutic drugs, and we’ve seen great progress in the application of these as well as recent FDA approvals.

So one of these is an agent called venetoclax (Venclexta), which is a BCL-2 inhibitor and venetoclax in combination with hypomethylating agents such as azacitidine (Onureg or Vidaza) has shown a response to close to 75 percent. 

And the nice thing is that this regimen can be given and patients who are older than 70, 75 years of age, and even those who are having comorbidities are not fit for traditional intensive chemotherapy with similar response rates, so this has been approved in the last couple of years for the frontline treatment of AML, and we’ve been using this combination of venetoclax and azacitidine quite frequently with high efficacy in this patient population, the other new agents that have shown breakthroughs in AML are the targeted therapies, these include FLT3 inhibitors that target the FLT3 mutation and these have shown good activity, but the single agents with gilteritinib (Xospata) being approved in the relapsed refractory setting as a single agent where gilteritinib showed a response rate of about 50 percent as a single oral targeted therapy in relapsed FLT3-mutated AML, which is actually better than the response rate with high-dose combination more where the response rate is only about 25 to 30 percent.

So, gilteritinib is now approved, and it’s now moving and being evaluated in frontline setting other FLT3 inhibitors like lestaurtinib (CEP-701), actually just recently completed frontline studies showing improved outcome when lestaurtinib added to intensive chemo versus just intensive chemo in FLT3 in AML. And we hope and think there’s a good chance lestaurtinib will be approved in the near future.

And also IDH inhibitors have been approved both in the relapsed setting, frontline setting, and now we even have a third group of targeted therapy is called the menin inhibitors, they target MLL rearrangement and NPM1 mutations, which are seen in about 15 percent to 20 percent of the AML, so there’s been a lot of progress.

All of this in the last seven years, six, seven years with multiple targeted therapies, with multiple inhibitor-based treatments, showing progress in AML and then also recently, the concept of maintenance therapy, this is something we used for the last couple of decades in a acute lymphoblastic leukemia and multiple myeloma and in lymphoma.

But we had not had clear data in AML, but the recent study using oral formulation of a azacitidine in CC486 has shown the maintenance in patients who complete an induction consolidation and could not go to allogeneic stem cell transplant for one reason or the other was important and improve both overall survival and relapse-free survival, and so this is the first time now we have an FDA-approved and standard use of maintenance therapy after the traditional induction consolidation, so even changing the general paradigm of AML therapy.

So a lot has changed in the last seven to eight years in the treatment of acute myeloid leukemia, and this is very exciting.

And the activation tip related, this question is that there are multiple new targeted and low intensity therapeutic options available for patients with acute myeloid leukemia, and in our institution, in my opinion, even older patients are eligible for some form of therapy or the other…very few patients, if any, today, are being sent to hospitals or palliative care without treatment.

So it’s very important to really consider all the available treatment options and if needed to seek consultation with an expert or academic center to get the most up-to-date treatments available for AML. 

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Treating Relapsed/Refractory DLBCL

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Treating Relapsed/Refractory DLBCL from Patient Empowerment Network on Vimeo.

What are the options for DLBCL patients who relapse? Dr. Jane Winter shares treatment options for relapsed/refractory DLBCL and what is available for patients who have coexisting conditions or health concerns.

Dr. Jane Winter is a hematologist and medical oncologist at Robert H. Lurie Comprehensive Cancer Center at Northwestern University. More information on Dr. Winter here.

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Transcript:

Laura Beth:

Dr. Winter, if a DLBCL patient doesn’t respond to treatment or relapses, what happens next? Are there additional treatment options available?  

Dr. Winter:

Absolutely, but we have some very new treatments and some new data that’s just been within the last year. So, I had mentioned earlier with regard to follicular lymphoma this CAR T-cell therapy. So, CAR T-cell therapy is now approved for certain patients who relapse. So historically, in the past, patients who were young enough and robust, healthy enough to consider what we call an autologous stem cell transplant, so, high doses of chemotherapy with stem cell rescue was the standard of care for many years. But many patients would not be eligible for that kind of therapy, first, because they were too old or they had too many medical problems, what we call comorbidities.  

But also, because in order to have a good outcome with this kind of treatment, we need to first get the disease into remission, and that can prove challenging. So, for many years, though, what we call autologous stem cell transplant was the standard of care. But a disease that is most common in people in their mid-60s and above, this was not an option for many patients, but also, many patients just never became eligible because their disease was too difficult to control. And so, in recent times, over the past six years or more, a new therapy called CAR T-cell therapy has emerged.  

This harnesses the patient’s own T cells. The T cells are collected from the blood stream, and then they are genetically engineered so that they target the marker on the lymphoma cells. It takes about three weeks or so to go through the process of altering these cells and creating these CARs, and then re-infusing them back into the patient now targeting the patient’s lymphoma. And, this is a therapy that’s incredibly promising.  

It was approved a while ago for patients in the third line, meaning if your disease came back after your first treatment, let’s say, R-CHOP, and then you receive second line treatment, but that treatment didn’t really work, you were a candidate for CAR T-cell therapy. And about 35 to 40 percent of patients would do very well with that therapy. It’s not a hundred percent, but still, it was a very good option for individuals. Now, we have clinical trials comparing patients who relapse. So, at the time the first relapse, if that relapse occurs within a year or the patient progresses while on initial treatment, CAR T-cell therapy has been shown to be better than the old standard of care, which was the second line of treatment in the stem cell transplant.  

So, we now have this very promising new strategy for patients as well as for a subset of patients who are not eligible to go on to conventional autologous stem cell transplant because they’re too old or they’ve got a heart disease or some other comorbidity that makes them not a candidate for a standard stem cell transplant. So, this is very exciting and is approved for patients with relapsed disease, or refractory disease, or disease that progresses during initial treatment, or recurs within a year as well as this group of patients who are either too old or too sick to have an autologous stem cell transplant.  

But, there are many new iterations, new variations on this theme that are under investigation right now. So, there are lots of clinical trials to consider for a patient with relapsed disease or refractory disease because we have new versions of CAR T-cell therapy that are under investigation as well as a whole list of new agents, targeted agents and what we call bite antibodies and so on.  

So, things are very promising and there’s a tremendous amount of research going on right now, much of it translating into improved responses and survival for patients with diffuse large B-cell lymphoma. 

Why Should Prostate Cancer Patients Be Empowered?

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Why Should Prostate Cancer Patients Be Empowered? from Patient Empowerment Network on Vimeo.

Prostate cancer researcher Dr. Andrew Armstrong explains how he empowers his patients and describes the positive benefits of speaking up in your own care.

Dr. Andrew J. Armstrong is a medical oncologist and director of clinical research at the Duke Cancer Institute’s Center for Prostate and Urologic Cancers. For more information on Dr. Armstrong here.

See More from Engage Prostate Cancer

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Transcript:

Katherine Banwell:

How do you empower patients? 

Dr. Armstrong:

Well, I empower patients by talking and listening. So, listening probably the most important part. Just getting to know somebody and their family is empowering them. You’re understanding their values, their preferences, understanding what side effects they’ve experienced in the past, what comorbidities or health conditions they’re facing, what their fears are. You know, what spiritual values they might bring, what support systems they might bring.  

Every patient is different, and part of a consultation is getting to know the person in front of you, and that empowers them to be honest. Empowers you to be transparent and get to know them so that you can help them sift through a complex decision. 

Giving information is really important, so I do a lot of talking as well as listening. 

But giving information back to the patient about risks and benefits of treatment A, B, or C or no treatment is critical. And then there is a lot of then listening to that shared decision about what might be right for that patient and navigating it. 

Katherine Banwell:

Why is it important for patients to be empowered? 

Dr. Armstrong:

It’s important for patients to be empowered, because this can often be a life-threatening decision. It’s important because this is ultimately their decision for their body, and making this decision can have major consequences that patients have to live with. Doctors empower patients to make the right decisions so they’re comfortable and don’t have regrets looking back on life and these important decisions. Whether this is picking surgery or radiation, or picking initial surveillance, or enrolling on a trial, or starting hormonal therapy. 

I think each decision sometimes is reversible, but sometimes is a big decision that can’t be taken back, and making sure that that patient feels empowered, that they don’t have regrets later, that they’ve gotten all the information to make an informed decision is really critical. 

Considerations When Choosing an AML Treatment

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Considerations When Choosing an AML Treatment from Patient Empowerment Network on Vimeo.

AML expert Dr. Eytan Stein reviews factors that should be considered when choosing an AML treatment approach, including potential side effects, age, and patient preference. 

Dr. Eytan Stein is a hematologist oncologist at Memorial Sloan Kettering Cancer Center and serves as Director of the Program for Drug Development in Leukemia in Division of Hematologic Malignancies. Learn more about Dr. Stein, here.

See More from Thrive AML

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Transcript:

Katherine Banwell:

All patients are different, of course, and what might work for one person might not be appropriate for another. How do you choose which treatment is right for a patient? 

Dr. Eytan Stein:

So, it’s an individualized decision. So, what you’re talking to the patient, as we talked about at the very beginning, is you really need to understand the patient’s goals for treatment. You need to understand the anticipated benefit of the treatment that you’re offering and need to understand the side effects of the treatment. 

So, and that sort of becomes the puzzle that you work with the patient at putting together. That is how well do I expect this treatment to work? What are the potential side effects of the treatment, and what are the patient’s goals? And when you sort of lay all those different pieces out, you then usually come up with something that becomes pretty clear what the best thing to do is.  

So, I’ll give you just a very concrete example of this. Sometimes, we have treatments where the medical data would suggest that they might work as well as one another, right? There’s no clear difference between each of the two treatments. But maybe one of the two treatments requires you to be in the hospital, and one of the treatments allows you to be at home.  

So, that’s an important discussion to have with the patient because some patients, believe it or not, want to be in the hospital, because they’re worried about being at home and having to manage this all themselves. Some patients don’t want to be in the hospital. Some patients want to be at home, because they’re scared of the hospital, or they’re worried the food’s going to be terrible.  

And then, that would be important in helping the patient make the decision for their treatment. 

Katherine Banwell:

Right. You mentioned earlier, Dr. Stein, the difference in ages and how you would treat different people depending on their age. So, when you’re choosing a treatment, you obviously look at age. What else? Things like comorbidities? 

Dr. Eytan Stein:

Yeah, so age, so I’m not ageist. So, it’s more that as people get older – and this is just a fact of life – as everyone gets older, their organs don’t work quite as well anymore, right? Things start breaking down as you get older. So, certain treatments aren’t appropriate for older people because the treatments a younger person, because their organs are working at 100 percent, may be able to handle it, while an older person, where their organs might only be working at 60, 70 percent, the treatment might not be as good of a choice for them. 

So, that’s what I mean. So, as people age, their comorbidities increase. So, we always look at comorbidities, and if you had an 80-year-old that was running marathons, I might think about their treatment differently than an 80-year-old who is not running marathons. But most 80- and 85-year-olds aren’t running marathons, so that’s why we sometimes think about their treatment differently. 

How Is Advanced Non-Melanoma Skin Cancer Treated?

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How Is Advanced Non-Melanoma Skin Cancer Treated? from Patient Empowerment Network on Vimeo.

Developments in advanced non-melanoma skin cancer treatment and research continue to evolve. Dr. Anna Pavlick reviews important treatment considerations and discusses targeted therapy options.

Dr. Anna Pavlick is a medical oncologist with over 20 years of experience treating patients with skin cancer and is the founding Director of the Cutaneous Oncology Program at Weill Cornell Medicine and NewYork-Presbyterian. To learn more about Dr. Pavlick, visit here. 

 

Katherine:

How is advanced non-melanoma skin cancer treated? 

Dr. Pavlick:

Everybody’s locally advanced non-melanoma skin cancer really has to be looked at as a personal type of management. 

There is no cookie-cutter answer to say, “Well you just cut it out, or you just radiate it.” Again, it’s going to be contingent upon where is this located, how extensive is it, what is the patient’s preference, what is the patient’s performance status? You know, when you talk about offering radiation, although it’s a very good therapeutic option for many of these tumors, there are some patients who can’t travel hours to get to a radiation facility, and radiation is given every day for several weeks. So that’s an option – though it’s a treatment option, it may not be a feasible option. And so I think there are multiple factors. If you cut it out, is the patient going to be left with a disfiguring outcome? 

I know many times I get sent older patients because this is a disease many times of older patients, where they have these very large lesions and the thought of doing a surgery – not that you can’t – but can the patient withstand such an extensive procedure? What are they going to look like and what kind of functional deficits are you going to leave them with? You know, all of this really has to come into play, and then again, is the patient well enough tolerate a medical therapy that I have to offer? So this is why when you deal with these cancers, it really is a group effort. We all know the patient. We all get to see the patient. 

And then we all get together and say, “Okay, what are the pros and cons, and really what is the optimal way for us to best serve this patient to get rid of their cancer but also preserve their quality of life?”  

Katherine:

So other than surgery what other options are available to patients? 

Dr. Pavlick:

So surgery’s obviously the first and foremost because if you can take it out, it’s a one-and-done, patient can heal, patient can move on. 

But again, depending on location, depending on extent of the disease, sometimes we consider radiation therapy, sometimes we consider medical therapy, which would mean using different types of systemic therapies, whether it be pills – depending upon the type of cancer it is – or even intravenous immunotherapy to help either control this disease and shrink it up, then allowing the surgeon to go in and remove it. Or, best case scenario is that the immunotherapy will completely eradicate the tumor and spare the patient from having to undergo any type of procedure.  

Tools for Choosing the Right Prostate Cancer Treatment Approach

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Tools for Choosing the Right Prostate Cancer Treatment Approach from Patient Empowerment Network on Vimeo.

Dr. Rana McKay discusses the factors that impact advanced prostate cancer treatment decisions. Dr. McKay reviews potential treatment side effects and explains how patients in treatment are monitored.

Dr. Rana McKay is a medical oncologist at UC San Diego Health and an associate professor in the Department of Medicine at the UC San Diego School of Medicine. Learn more about Dr. McKay, here.
 
 

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Tools for Partnering in Your Prostate Cancer Care

Transcript:

Katherine Banwell:

Since prostate cancer affects men differently, let’s review what factors could impact which treatment is right for their individual disease. How about we start with symptoms? 

Dr. Rana McKay:

So, yeah. I mean absolutely. I think symptoms are definitely something that plays into effect. Sometimes when patients are first diagnosed, they may not have symptoms. But, you know, boney pain, symptoms of urinary obstruction. You know, there’s specific treatments and strategies that we can deploy to help with those kinds of things. You know other factors that I think I – we take into account when we’re making decisions about which agent should any one patient receive is where are their sites of metastases? Is there disease just in the bones and lymph nodes or are there other organs involved? What’s the genomic make-up of the tumor? There are certain treatments that we would utilize if someone had a certain specific you know, genetic make-up for their tumor. You know, other things that are really important are what kind of drugs has the patient seen before or has that tumor been exposed to? Because that also helps us strategize for what to give them in the future.  

Katherine Banwell:

Do you take into consideration the patient’s comorbidities and their age and overall health? Things like that?  

Dr. Rana McKay:

Absolutely. Yeah. I think we need to absolute take that in account. I think – I think age is one thing. But I think functional status is just as – as important as the actual number itself because people are very different regarding the things that they can do at various age limits and so, that absolutely takes into account weighing the side effects of any given therapy and how that may interact with someone’s existing comorbidities and it may be something that we have to work with a team of other doctors to basically make sure that there is comprehensive, well-rounded care for any one patient.   

For example, some therapies may increase the risk of hyper-tension or increase the risk of volume overload. And so, if somebody has issues with that already we may have them see a cardiologist so we can make sure that, you know, we’re kind of addressing the totality of the patient experience. 

Katherine Banwell:

What do you mean by volume overload? 

Dr. Rana McKay:

Volume overload, I mean if they’ve got too much fluid on board. So, maybe if they have heart failure or something like that, and we have a therapy that’s going to cause them to retain fluid. And so then, we would have to work with a cardiologist to make sure that they don’t run into issues.  

Katherine Banwell:

Mm-hmm. Once a man is undergoing treatment for advanced prostate cancer, how are they monitored to see if it’s actually working? 

Dr. Rana McKay:

So, a lot of ways. So, one is by just, you know, visiting with the patient. Making sure that their symptoms are in check. Making sure that they’re not developing new aches or pains that are worrisome. It’s by checking their labs in addition to their organ and bone marrow function. We would check their PSA. And PSA isn’t the whole story. But it is one factor that contributes to us determining whether treatment may or may not be working. It’s also doing intermittent scannings. So, you know, CT scans of the organs, of the lymph nodes. Bone scan and now we actually have PSMA based imaging, which can be integrated to help assess where the disease is and not yet being utilized to assess whether something is working, because we haven’t really defined the criteria there. But, it can be utilized as well.  

Which Factors Impact Advanced Prostate Cancer Treatment Decisions?

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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

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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?

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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

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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

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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

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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.