Tag Archive for: KRAS

Advances in Targeted Lung Cancer Treatments | What You Should Know

Advances in Targeted Lung Cancer Treatments | What You Should Know from Patient Empowerment Network on Vimeo.

Dr. Thomas Marron discusses how these therapies work to treat lung cancer, how the presence of certain mutations can impact care and treatment choices, and the research being done on new therapies to target specific lung cancer biomarkers.

Dr. Thomas Marron is Director of the Early Phase Trials Unit at the Tisch Cancer Institute at Mount Sinai Hospital. Dr. Marron is also Professor of Medicine and Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. Learn more about Dr. Marron.

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Transcript:

Katherine Banwell:

Welcome, Dr. Marron. Would you introduce yourself, please? 

Dr. Thomas Marron:

Sure, I’m Tom Marron. I’m the Director of the Early Phase Trials Unit at the Tisch Cancer Institute at Mount Sinai Hospital. I’m a Professor of Medicine and also a Professor of Immunology and Immunotherapy at the Icahn School of Medicine at Mount Sinai. And I’m trained as both an oncologist and an immunologist.  

Katherine Banwell:

Excellent. Thanks for joining us today.  

Dr. Thomas Marron:

Thank you for having me.   

Katherine Banwell:

We know that the presence of certain mutations can affect lung cancer treatment options. Can you share the latest updates in targeted therapies?  

Dr. Thomas Marron:

Sure, so there’s been a lot of developments in targeted therapies as of late.  

Mutations in a patient’s cancer can represent a potential therapeutic target, and we have increasing numbers, every year we have new FDA approvals for typically pills that target very specific mutations and are able to either control cancer or even kill cancer. Additionally, we use DNA sequencing of tumors to identify mutations that could be predictive of a response to certain therapies. So, even though we don’t have a specific drug to target that mutation in their DNA, that change in their DNA that’s making the cancer grow, we do know that patients with certain DNA mutations do better on certain therapies than other therapies.  

And so, we can use mutations specifically to help guide therapy, even if we don’t have a targeted therapy for something like EGFR mutation or a KRAS mutation. And additionally, one of the things that we do as we’re treating patients is, often times we will give a patient with lung cancer a therapy and then their cancer may respond for weeks, months, even years.  

But then it might recur, or it might just start growing if it never went away entirely. And at that time, we’re oftentimes repeating the genetic sequencing, whether doing a biopsy or sometimes we can do what we call a liquid biopsy, which is just taking some blood and looking for some of the DNA from the cancer floating around in the blood.  

And the reason we do that is that if you see a change in the mutations, it might represent either a change in the type of cancer or it might represent what we call an escape mutation, or an escape mechanism where the cancer that had been responding to therapy X is now not responding because it changed its DNA to overcome the therapy you were given. And that might suggest that we try a specific new therapy, or that we just change our approach entirely.  

Katherine Banwell:

You’ve answered my next question to some degree, but I’m going to ask it anyway. How do these therapies work to treat lung cancer? 

Dr. Thomas Marron:

So, cancer is caused by changes in your DNA. So, your DNA is your instruction booklet on how cells should grow and when they should grow. And every cell in your body theoretically has the same DNA, except for, because of a variety of things like smoking or exposure to radon or just living in a large city full of pollution. As we get older, we basically accrue more and more mutations and changes in our DNA, our instruction booklet. And while most of these changes really don’t have any sequela, and they’re not going to affect the ability for the cancer, or for normal cells to grow.  

Sometimes you’ll get a mutation in a very specific gene that’s important for telling cells when to divide and when to grow and when not to grow. And you can think of it as a light switch where the light switch gets stuck in the on position and constantly, cells are growing and growing and growing and that’s when you have cancer. So, when you have these mutations, one of the approaches that we’ve been working on for the last few decades, in particular in the last few years.  

We have lots of these new drugs that target these mutations, and they basically turn that on signal off. So, they disrupt, it’s like turning the light switch off. You’re disrupting the constant grow, grow, grow signal and keeping the cancer from growing. Typically, we think of these targeted therapies that do this, not as cures for cancer, at least when patients have metastatic disease, but they’re very good at controlling cancer. And some of these therapies can work for years, even a decade and control the cancer. But often times, unfortunately cancer always finds a way to outsmart us, even when we’re outsmarting it.  

Katherine Banwell:

Right. Are there new mutations being discovered that can impact the future of small cell lung cancer care? 

Dr. Thomas Marron:

Well, I’m not sure I would say that there’s a lot of new mutations that’ve been discovered, per se. Every time that you come in and get a diagnosis of lung cancer, we typically will take the tissue and like I said, sometimes we’ll take some blood and do a liquid biopsy and look for a slew of different known mutations.   

And typically, we’ll look for anywhere from three to 500 known mutations in the cancer, even though we only have drugs to treat about 10 of those three to 500. The nice thing though is that as we learn more and more and more about these mutations and we study them, we are developing more and more drugs to address specific mutations. So, five years ago we really only had three different mutations that we could target.  

Now, we have around 10 because we have all these new drugs that target very specific mutations whether they be in genes like MET or RET or KRAS or BRAS.  

So, I think that while we aren’t necessarily discovering that many new genes, we’ve been looking at the genetic sequence of cancer and also, just the human genome for 20 to 30 years at this point, we’re discovering lots of new drugs that can target those specific mutations that we know patients have, but that most of the mutations we identify are not necessarily druggable targets.  

Hope Unleashed: Advancing Therapies for Defiant Mutations in Lung Cancer

Hope Unleashed: Advancing Therapies for Defiant Mutations in Lung Cancer from Patient Empowerment Network on Vimeo.

What promising studies in lung cancer mutations are there that patients should know about? Expert Dr. Joshua Sabari from NYU Langone discusses common lung cancer mutations, incidence rates, promising and potential studies, and proactive patient advice.

[ACT]IVATION TIP

“…no matter what your lung cancer type is, no matter any clinical characteristic, you need next generation sequencing done, biomarker testing done, to identify these mutations. And even when we identify the mutation, I think as a group, as an academic community, we need to do more to study novel therapeutics and to better understand the biology of these mutations so that we can get better treatments to our patients.”

Download Resource Guide  | Descargar guía de recursos

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Transcript:

Lisa Hatfield:

Dr. Sabari, can you speak to some of the more defiant mutations in lung cancer, and what promising studies are we looking at right now?

Dr. Joshua Sabari:

Yeah, so I think in lung cancer the most common mutations that we see are EGFR and KRAS. EGFR mutations are a quite broad range of alterations. The most common are in exon 19 deletion and exon 21. These are the location of the mutations. They make up about 80 percent to 85 percent. We have phenomenal treatments in the frontline setting, but most patients only remain on therapy for about two years before there is progression. So, we need to better understand resistance mechanisms, and we need to better understand the next generation of therapies that are available.

In contrast to EGFR, KRAS is equally as common. We see this in about 25 percent to 30 percent of the patient population. Unlike EGFR, KRAS is almost exclusively seen in people who’ve smoked in the past. And there are many different KRAS mutations or alleles. There’s KRAS G12C where we have two FDA-approved match targeted therapies in the second-line setting.

But we need better options, better opportunities for our patients in the frontline setting. And for KRAS, we’re not doing as well as we should, right? KRAS mutations, most people have about a 30 percent to 40 percent chance of responding to therapy. And the median time on treatment is in that six to seven month range. So this is a defiant mutation. It’s a mutation where we need to do better and we need to really develop the next generation of inhibitors for our patients.

So I guess the activation tip here is, again, no matter what your lung cancer type is, no matter any clinical characteristic, you need next generation sequencing done, biomarker testing done, to identify these mutations. And even when we identify the mutation, I think as a group, as an academic community, we need to do more to study novel therapeutics and to better understand the biology of these mutations so that we can get better treatments to our patients.


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Advances in Small Cell Lung Cancer Research | Hope for the Future

Advances in Small Cell Lung Cancer Research | Hope for the Future from Patient Empowerment Network on Vimeo.

What new treatments are being studied for small cell lung cancer (SCLC)? Dr. Triparna Sen, a leading researcher in the field, shares promising updates, including advances being made with LSD1 inhibitors, DDR (DNA Damage Response) inhibitors, and DLL-3 targeted therapies.

Dr. Triparna Sen is an associate professor in the department of oncological sciences and co-director of the Lung Cancer PDX Platform at the Icahn School of Medicine at Mount Sinai in New York. Learn more about Dr. Sen.

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Transcript:

Katherine:

Dr. Sen, you are a leading researcher in the field. What is the latest research news that you can share with us about small cell lung cancer?

Dr. Sen:

There’s a lot of great research going on in my lab and labs all across the world. I think for the first time in a very long time, we are really trying to dissect the biology of small cell.   

It has been a research in making for many years. I think we have now really come to a point where we are really trying to understand the disease. I’ll go into a little more about the questions you are trying to answer. So, one of the main questions or one  of the main things that kind of is a hurdle to getting durable treatment options is that the frontline chemotherapy and immunotherapy doesn’t work as well as they should even for the approved regimens, which is the chemotherapy and the immunotherapy.  

The patients often do not have durable benefits. Even if patients have durable benefits, it’s only in a very minority of patient population which means in only about 10 to 15 percent of the total patient population actually do have any benefit from the frontline treatment. So, the main question that we are trying to answer is that why do these patients not respond to immunotherapy and chemotherapy in the frontline.  

What are the mechanisms of resistance to chemotherapy and immunotherapy? Primary resistance, what I mean by primary resistance is that patients who never respond. The disease comes back even while they’re getting the frontline chemo. So, the primary resistance, the mechanisms. Of course, when they have acquired resistance after the maintenance regimen when they come back, why are these patients having this acquired resistance to chemotherapy and immunotherapy? Because only when we understand resistance mechanisms will we be able to then come to the combination strategies.

That’s the next area of research is that once we understand the mechanism of chemotherapy and immunotherapy resistance is then coming up with effective combination therapy. So, what should we combine with immunotherapy in order to make immunotherapy better? I’ll give you an example from the research that we did. 

So, our lab focus is, as I said, on making immunotherapy better. What we understood is that there are certain epigenetic modifiers like LSD1.  

Repressing these, repressing LSD1, with a small molecule inhibitor actually augments or benefits the response to immunotherapy. So now, we are looking at LSD1 inhibitors in combination with immunotherapy. That’s one area that we are focusing on. The second are that we published extensively on is DNA damage response inhibitors which really works in combination with immunotherapy and makes immunotherapy response better.  

Now, we are investigating that in the lab the combination strategies of combining these DNA damage response inhibitors with immunotherapy. So, combination strategies. I think always coming up with novel targets. I will mention there are many novel targets that are right now in the clinical trials actually showing really, really encouraging data.  

I’m talking about DLL3 targeted BiTEs or ADCs we have seen that are showing preliminary data. We have seen a really good really good response in patients. So, finding these targets that are very specific for small cell and that can work in these unique population of patients.  

So, DLL3 targeted agents. There are agents that target B7-H3. So, we are looking at these novel targets and where they could fit in the current therapeutic regimen. Finally, since small cell lung cancer is not a surgical disease, we have to look for other options to find biomarkers. So, liquid biopsy. Liquid biopsy, what I mean by that is understanding the disease not just from tissue but also from blood.  

There’s a lot of research that’s happening in understanding the biology of small cell from blood draws from these patients.  

So, the field of using liquid biopsy or understanding the disease from blood draws is one of the areas that many labs, including ours, are focusing on, and how we can utilize these blood samples to then monitor the disease and also understand the resistance mechanisms to various drugs. I think these are the areas that we are investigating and seems, to me, very important areas that we need to address in order to really manage small cell lung cancer.   

Katherine:

What do these advances mean for small cell lung cancer patients? Are you hopeful?  

Dr. Sen:

Oh, yes. Of course. We’re always hopeful. That’s the goal, right. The goal is to have effective therapies that work and that works for a long time. That also benefits the patients in terms of quality of life which means without very severe adverse effects.   

So, very hopeful. Because I think what was limiting us for all those years for the last 40 to 50 years is that we really did not understand the complexity of small cell lung cancer. It is a very complex disease. It is very different from non-small cell lung cancer which has these mutations that you can target drugs against. So, there are this EGFR mutations and KRAS mutations in non-small cell.  

But small cell, it’s not that. It is not a disease where we have these GATA function mutations that we can devise therapies against. It’s a very different disease. The disease is aggressive. The disease progresses fast, and it also changes its physiology very fast. So, I think for the first time, we really are trying to understand the biology. What that helps is then to come with very informed decisions about therapy.  

So, yeah, I’m very hopeful. Because I think we have now targets that we are actually seeing benefits in patients. I think the more and more we understand resistance mechanisms, we’ll also be able to manage that better.   

Katherine:

That’s very promising news. 

Understanding Small Cell Lung Cancer Treatment Options

Understanding Small Cell Lung Cancer Treatment Options from Patient Empowerment Network on Vimeo.

How is small cell lung cancer (SCLC) treated? Dr. Triparna Sen discusses treatment options for patients with small cell lung cancer, both first-line and second-line therapies, and the important role of clinical trials in patient care. 

Dr. Triparna Sen is an associate professor in the department of oncological sciences and co-director of the Lung Cancer PDX Platform at the Icahn School of Medicine at Mount Sinai in New York. Learn more about Dr. Sen.

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Advances in Small Cell Lung Cancer Research | Hope for the Future

Transcript:

Katherine:

How do test results impact care? 

Dr. Sen:

So, you know, once the doctor has confirmed the small cell lung cancer and we have confirmed what stage it is at – what I mean by staging is that it could be either a limited stage disease which is an early stage small cell, or it could be an extensive stage of small cell. The treatment for those two are quite different. So, if it is an early stage or limited stage, patients are usually treated with chemoradiation. If it is an extensive stage or a metastatic small cell, then patients are usually given a standard of care which is chemotherapy in culmination with immunotherapy which is an antibody against PD-L1.  

Katherine:

You’re talking about treatment options that are currently available for small cell lung cancer. What about targeted therapies?  

Dr. Sen:

There aren’t very many therapeutic strategies that are targeted therapies as we speak like we hear from non-small cell lung cancer.  

So currently, like I mentioned, the frontline treatment for small cell lung cancer is with chemotherapy and immunotherapy and maintenance with immunotherapy alone.  

Once the patient relapses, which often is the case – all patients actually have resistance to the frontline chemo-io (chemoimmunotherapy) at some point in time. Once they have a relapse disease, the second line of therapy until now is with either topotecan or irinotecan which are two topoisomerase inhibitors or with lurbinectedin which is in the second line.  

So, when it comes to targeted therapies, so far we a have seen, you know, the conventional way that we think about EGFR inhibitors or KRAS inhibitors, it hasn’t been the case so far with small cell lung cancer. It’s very limited in the current approved setting. But there are many clinical trials that are investigating several targeted therapies that are either targeting – I can speak about that more as I talk about research strategy. But there are many targeted agents that are targeting surface targets like DLL3, B7-H3, or SEZ6. There are other targets that are targeting things like DNA damage repair, proteins, or epigenetic regulators like LSD1. But so far in the approved setting, it is quite limited.  

Katherine:

When we look at what therapies are available, what treatment options are available, what are some typical side effects? How are they managed?  

Dr. Sen:

Some of the major side effects that you see, especially with a frontline chemo-io (chemoimmunotherapy), are very common like you see with other cancer types. Also, it’s usually myelosuppression.  

I think it is prevented or is managed either by dose reduction or treatment delays or treated with transfusion. There has been research that CDK4/6 inhibitors, trilaciclib, when treated with in combination with chemotherapy can bring down the side effects that we see with chemotherapy.  

Some of the immunotherapy related adverse events includes pneumonitis, colitis. They are usually treated with early steroids, treatment withholding, and also it could be leading to permanent discontinuation of the treatment if the adverse events are really severe. Those are mainly what we see we the chemo-io (chemoimmunotherapy) regimen that is given up front.  

Katherine:

Okay. What questions should someone be asking about their proposed treatment plan?  

Dr. Sen:

Right. So, I think, of course, first is what stage. The treatment will depend upon the stage of small cell. Usually, on the frontline, everyone is given chemotherapy and immunotherapy. 

It’s a systemic therapy that’s being given. But I think the patient should be asking questions like are there clinical trials available for me. Because there are multiple clinical trials right now in the frontline and the second line setting.  

So, I think definitely the patient should ask about the clinical trials that the qualify for. In terms of contributing to research, I think if there are options for them to either sign up for blood collection protocol or for tissue collection protocol, I think the patient should definitely enroll for that.   

Because that really helps our research strategy. But in terms of treatment, I think they should ask about available clinical trials that they qualify for.  

Katherine:

Let’s turn to clinical trials then. Patient participation, of course, is essential to finding new and better treatments. What would you say to someone who’s hesitant to participate in a clinical trial?  

Dr. Sen:

Yes. I mean, that’s often the thing. We hear about these novel drugs. They’re in trial. For a disease that’s that aggressive, I think once there is a relapse, I think clinical trials could be a very good option for patients. These are novel drugs that have come out of very robust research that we do in the lab. They can often work quite a bit. So, I think, of course, talk to your physicians. Talk to them at length about whether you do qualify for it. But if there is a trial at the center that you’re getting treated at and if the doctor advises that, I think enrolling in a clinical trial could be a very good option for patients, especially in the aggressive setting where there are not many options available for patients.  

As I mentioned here, research is my true north. I mean, all my lab does is understanding the biology of small cell. It’s extremely essential that we actually try to get the knowledge of the patient tumor. So, if you have availability of contributing either in terms of tissue or blood to research, I think I would advise and encourage patients to definitely contribute to that. 

What Essential Testing Reveals About Your Non-Small Cell Lung Cancer

What Essential Testing Reveals About Your Non-Small Cell Lung Cancer from Patient Empowerment Network on Vimeo.

What do lung cancer test results reveal to your healthcare team about your disease? Dr. Isabel Preeshagul provides an overview of essential testing for lung cancer and explains the difference between germline and somatic mutations.

Dr. Isabel Preeshagul is a thoracic medical oncologist at Memorial Sloan Kettering Cancer Center. Learn more about Dr. Preeshagul.

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Transcript:

Katherine Banwell:

I’d like to turn to the clinical side of non-small cell lung cancer. What tests help you identify the type and stage of lung cancer? 

Dr. Isabel Preeshagul:

Obviously, you need a CAT scan. You need a CAT scan of the chest, abdomen, pelvis, and you need an MRI brain and a PET scan.  

Those are really the gold standards for determining clinical staging. In regards to pathologic staging, it’s really important to have tissue samplings. So, you biopsy a site of disease that’s concerning to you. If it looks like there’s only disease in the chest, you want to biopsy the site where there’s the tumor, and then you talk with your thoracic surgery or pulmonary team to determine the best way to sample the mediastinum for full staging.  

Katherine Banwell:

Why is an accurate diagnosis so important? 

Dr. Isabel Preeshagul:

So, an accurate diagnosis is so important, because lung cancer is by no means black and white anymore. There are so many histologic subtypes that we are learning about. There are so many different molecular drivers that we are learning about. So, making sure you have the right diagnosis, full and next-generation sequencing testing, all of the imaging that you need could really make or break your treatment plan.  

Katherine Banwell:

Dr. Preeshagul, let’s talk about biomarker testing. How is biomarker testing for lung cancer different from hereditary genetic testing? 

Dr. Isabel Preeshagul:

So, we do do hereditary genetic testing for lung cancer patients as well. So, I think let’s backtrack a little bit. When you’re doing on a patient, there are germline mutations and there are somatic mutations. And germline mutations are mutations that you might get from Mom and Dad that they got from their parents and so on and so forth that you could give to your children or your brother and sister or whatever. So, that’s germline testing that could be passed along.  

That would be like BRCA or any other APC gene, but we are learning more and more that there are mutations in lung cancer that do have a hereditary aspect to them. So, we are learning now that while we do somatic testing, which is to find a mutation that just spontaneously happened in your tumor all on its own, it’s really important to pair that with germline testing to make sure that there isn’t some kind of heritable mutation that’s also driving this lung cancer.  

Katherine Banwell:

You mentioned hereditary genetic testing. Should family members of people with lung cancer undergo genetic testing then just to be reassured? 

Dr. Isabel Preeshagul:

So, if there is a germline mutation, then they should – the family members should be referred to a geneticist to have that discussion.  

Katherine Banwell:

What are common lung cancer biomarkers? 

Dr. Isabel Preeshagul:

So, we have nine biomarkers within approval right now, but there are so many. There’s more than I could even talk about today. But some of the more common ones are EGFR, ALK, ROS1, MET exon 14. You have KRAS, KRAS-G12C, which is a newer one. We have NTRK. We have RET. The list goes on, HER2. I could talk for – there’s not enough time on this Zoom video to talk about all of the mutations. But there are nine mutations with approvals as of now to date, this very moment. That could change tomorrow.   

Which Tests Do You Need Before Choosing a Lung Cancer Treatment?

Which Tests Do You Need Before Choosing a Lung Cancer Treatment? from Patient Empowerment Network on Vimeo.

Why is it important to ask about biomarker testing for your lung cancer? Find out how test results could reveal more about your lung cancer and may help determine the most effective treatment approach for your individual disease.

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Transcript:

Why should you ask your doctor about biomarker testing?

Biomarker testing, sometimes referred to as molecular testing or genetic testing, identifies specific gene mutations, proteins, chromosomal abnormalities, and/or other molecular changes that are unique to YOU and YOUR lung cancer.

The analysis is performed by testing the tumor tissue or by testing tumor DNA extracted from blood to identify unique characteristics of the cancer itself.

So why do the test results matter?

The test results may predict how your lung cancer will behave and could indicate that one type of treatment may be more effective than another.

In some cases, biomarkers can indicate that a newer approach, such as targeted therapy or immunotherapy, may work better for you.

Common mutations associated with lung cancer include the EGFR, ALK, ROS1, BRAF, TP53 and KRAS genes, among others. In some cases, there are inhibitor therapies that target specific mutations. For example, if the EGFR mutation is detected, it may mean that an EGFR inhibitor, a type of targeted therapy, may work well for your type of lung cancer.

Another common biomarker associated with lung cancer is PD-L1. PD-L1 is a receptor expressed on the surface of tumor cells. The presence of PD-L1 indicates that a lung cancer patient may respond well to immunotherapy.

The results could also show that your cancer has a mutation or marker that may prevent a certain therapy from being effective, sparing you from getting a treatment that won’t work well for you.

Identification of biomarkers may also help you to find a clinical trial that may be appropriate for your particular cancer.

How can you insist on the best lung cancer care?

  • First, bring a friend or a loved one to your appointments to help you process and recall information.
  • Before you begin treatment, ensure you have had biomarker testing. Talk with your doctor about the results and how they may impact your care and treatment plan.
  • Finally, always speak up and ask questions. Remember, you have a voice in YOUR lung cancer care.

To learn more about lung cancer and to access tools for self-advocacy, visit powerfulpatients.org/lungcancer.

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.

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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.

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Transcript:

Katherine Banwell:

Welcome, Dr. Krishnamurthi. Would you mind Would you mind introducing yourself?  

Dr. Krishnamurthi:

Sure, it’s my pleasure. Thank you for having me, Katherine. I’m Smitha Krishnamurthi. I’m a medical oncologist. I specialize in taking care of patients who have colorectal cancer and other gastrointestinal cancers. As a medical oncologist, I treat patients with drug therapy like chemotherapy and immunotherapy.  

Katherine Banwell:

And where are you located?  

Dr. Krishnamurthi: I work at Cleveland Clinic in Cleveland, Ohio. 

Katherine Banwell:

Excellent. Thank you so much.  

Cancer researchers came together recently to share findings at the annual American Society of Clinical Oncology meeting, also known as ASCO. Are there highlights from the meeting that patients should know about?  

Dr. Krishnamurthi:

Yes. That’s always such an amazing gathering of knowledge. Thankfully, it’s continued virtually at least due to the pandemic. This past ASCO last month, some of the major highlights in colorectal cancer were the final overall survival results were presented from the study of pembrolizumab versus chemotherapy as first-line treatment for patients with metastatic colorectal cancer with deficient mismatch repair or MSI high status.  

These are the patients who are predicted to benefit from immunotherapy.  

We’d already seen earlier results that the patients who received the immunotherapy up front had a much-improved time for the cancer to regress. Here, they presented the overall survival results, which showed that the median survival for patients who received chemotherapy was three years, meaning half the patients lived shorter time, half lived longer. For the patients who received the pembrolizumab, they hadn’t even reached the median survival at five years.  

So, it looks very important that we know this MSI status or mismatch repair status from the beginning, so that we can offer the right patients immunotherapy first.  

Other highlights were, for example, for patients who have cancers that overexpress HER2/neu. It’s an oncogene. When it’s overexpressed, it tends to drive growth of cancers.  

 We don’t have any FDA-approved drugs for HER2-amplified colorectal cancer, but there are many studies showing that those patients with that type of cancer benefit from targeting this HER2 protein. There are, of course, approved drugs for HER2/neu-amplified breast cancer and stomach cancer. One of these drugs is trastuzumab deruxtecan.   

It’s a drug that targets the HER2/neu protein, but it’s connected with chemo. So, it’s like bringing chemo right to the tumor. The results showed a very high response rate. But it does have a peculiar toxicity of causing inflammation in the lung. So, it’s another treatment option that could be approved. It’s good to see that we’re getting more treatment options there. 

Katherine Banwell:

What are you excited about when it comes to colon cancer research? 

Dr. Krishnamurthi:

There are so many important questions we still need to learn the answers to. I find that patients who have, of course, a mutation of the KRAS or NRAS gene and have metastatic cancer, they have fewer treatment options than when those genes are normal. 

KRAS is a very important oncogene driver of cancer in colorectal cancer, but also in lung cancer and pancreatic cancer. For many decades, it was thought that there was no way to target this protein. Now, we’re seeing that there’s a certain type of KRAS mutation – KRAS G12C – that can be targeted with drugs that now are approved in lung cancer. 

It’s a small fraction of colorectal cancer patients who have that mutation, but it’s like we’re beginning to crack this code. The most common KRAS mutation is G12D. There is a company – Mirati – that has a candidate G12D inhibitor that’s going to enter clinical trials this year. It’s very exciting.   

There was recently a press release onvansertib, which is a polo-like kinase inhibitor, combined with chemotherapy, a second-line treatment for patients with KRAS-mutant colon cancer, showing a much higher response rate than we would expect with the chemotherapy alone.  

That will need to be validated in a large, randomized trial, but that’s looking very exciting. Then the other aspects that I’m most excited about are how to get immunotherapy to work for more of our patients.   

We know that patients who have abnormal mismatch repair or MSI-high cancers can benefit remarkably in the metastatic setting and there are studies going on in the early-stage setting and there are reports of it looking quite promising. But how do we get it to work for the majority of patients who have normal DNA mismatch repair or MSS, microsatellite stable cancers? That’s an area of great interest.  

We’ve seen a study in the Netherlands where they treated patients with normal DNA mismatch repair, early-stage colon cancer, with just two doses of immunotherapy before going to surgery for their early-stage cancer. I was surprised to see like four out of 15 patients responded to the treatment. Perhaps earlier stage cancers may be more responsive to immunotherapy. Definitely looking forward to more updates from that study, which we’ll probably hear in the fall at the European Society of Medical Oncology meeting in fall of 2021. 

Then, of course, the other area that really interests me is what is causing this epidemic of colorectal cancer in young adults? This is really a matter of laboratory studies and epidemiologic studies, but that’s also an area of great interest.  

Katherin Banwell:

There’s an epidemic among younger people?  

Dr. Krishnamurthi:

Yeah. I think of it as an epidemic in that colorectal cancer has definitely been increasing in young Americans and young people around the world in many countries.  

Basically, clearly, there’s been an increase since the 1980s. It seems to be something environmental because it’s related to time. So, it’s not inherited. Some of our patients below the age of 50 diagnosed with colorectal cancer do not have an inherited cause. A study from Ohio State found that 16 percent have an inherited cause. So, 84 percent of them do not. This is definitely increasing, particularly of rectal cancer. I think it must be something environmental. Possibly something like we’re ingesting because our colon is exposed to what we eat. But we really don’t know yet.  

And so, I just advise all my patients and everyone who is interested to just try to eat as much natural food as we can. To try to minimize processed foods and chemicals. 

Because I think that’s the best we can do until we really identify the cause.  

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.

See More From The Pro-Active Colon Cancer Patient Toolkit


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How Is Colon Cancer Treated?


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.

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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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.