Tag Archive for: University of Colorado Cancer Center

Expert Perspective | The Value of Empowering Patients

Expert Perspective | The Value of Empowering Patients from Patient Empowerment Network on Vimeo.

Lung cancer specialist Dr. Tejas Patil, of University of Colorado Cancer Center, explains why it’s important for lung cancer patients to feel empowered and discusses the advice he shares with patients to encourage self-advocacy.

Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.

See More from Thrive Lung Cancer

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Why Lung Cancer Patient Advocacy Is Essential

Why Non-Small Cell Lung Cancer Patients Should Speak Up About Symptoms and Side Effects

When to Consider a Clinical Trial for Lung Cancer Treatment?


Transcript:

Katherine:

Dr. Patil, how do you empower patients? 

Dr. Patil:

Well, I think transparency is key. So, I tell patients what I know. I tell patients what I don’t know. I help patients ask the questions that they may want to ask, but not sure how to.  

And I think for patients it’s really important to know that ultimately my role as a provider is to be a coach and a guide. And patients really have autonomy over their bodies and their choices. Sometimes I disagree with what patients choose to do, sometimes I agree. But I will think that as long as patients are aware of the risks and benefits of any decision they’re making and do it with information, that that’s a way of empowering patients. 

Katherine:

Why is it so important for patients to be empowered? 

Dr. Patil:

I think an empowered patient is actually a patient that can make meaningful decisions, and not make emotional decisions. I think that cancer diagnoses inherently are scary.  

They come with a lot of existential concerns and patients oftentimes feel like they’re cornered. And when patients are empowered, they can feel those emotions, but also make decisions that are based more on science and some on the facts that actually affect their care. 

Katherine:

Yeah. The more information we have, the more in control we feel. 

Dr. Patil:

The more in control you are actually. 

Katherine:

Yeah. Yeah. Very true.  

Collaborating on Lung Cancer Treatment Decisions With Your Team

Collaborating on Lung Cancer Treatment Decisions With Your Team from Patient Empowerment Network on Vimeo.

Lung cancer specialist Dr. Tejas Patil discusses why active communication between patients and their healthcare team is essential when making care and treatment decisions.

Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.

See More from Thrive Lung Cancer

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Expert Advice for Recently Diagnosed Lung Cancer Patients

Expert Advice for Setting Lung Cancer Treatment Goals

When to Consider a Clinical Trial for Lung Cancer Treatment?


Transcript:

Katherine:

Where does shared decision-making come into play? When does it come into play?  

Dr. Patil:

It comes in always.   

So, shared decision-making is one of the most important things that patients can do with their providers. It’s really important when we think about treatments to not just be very cookie cutter and follow a recipe book for managing a patient’s lung cancer. It’s really important to individualize therapy. This is really important where patients’ values come in. What patients want to do with the time that they have, and what patients want to do with the treatment? How do they want to take certain treatments?  

So, for example, I have a patient who’s a violinist and was faced with the possibility of receiving a type of clinical trial, but this trial caused neuropathy or numbness or tingling and would essentially render this patient unable to play the violin. This was an unacceptable treatment option for this patient, even though the data would suggest that it would work.  

And that’s an example of where shared decision-making comes in because it’s more than just treating numbers. It’s really about taking care of people. 

Katherine:

Yeah. Why is active communication between the patient and lung cancer team so important? 

Dr. Patil:

Active communication is really important because it’s really one of the easiest ways for things — So, a breakdown of communication rather is a one of the easiest ways for gaps to occur in care. And when there is active communication, when a patient feels like they have an opportunity to reach their team members to connect with their providers, it builds trust. And I think trust is one of the more important elements in the management of patients. If patients can trust their provider and trust that their judgment is sound, then there is more likely to be a harmonious relationship that facilitates the shared decision-making.  

Katherine:

When a patient is in active lung cancer treatment, how are they monitored? 

Dr. Patil:

So, patients are monitored in a variety of ways. If they’re receiving chemotherapy or immunotherapy, typically a provider will see the patient with each infusion cycle. And so, depending on the length of time and the schedule of infusions, that sort of dictates how frequently we see our patients. When patients are receiving targeted therapies, specifically the pill-based forms, they can be monitored in concordance with the NCCN guidelines. And in my practice, I typically see patients every three months with imaging.  

Now, if patients are having a hard time tolerating treatment, so they’re taking their oral pills but for whatever reason, we’re having a ton of side effects, we’re trying to figure out the dose. I might see my patients more frequently. But as a standard, if patients are tolerating their targeted treatment well, their scans look good, I usually see them every three months.  

Expert Advice for Setting Lung Cancer Treatment Goals

Expert Advice for Setting Lung Cancer Treatment Goals from Patient Empowerment Network on Vimeo.

Dr. Tejas Patil, a lung cancer specialist from the University of Colorado Cancer Center, shares advice on how lung cancer patients can work with their healthcare teams to set treatment goals.

Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.

See More from Thrive Lung Cancer

Related Resources:

Expert Advice for Recently Diagnosed Lung Cancer Patients

Collaborating on Lung Cancer Treatment Decisions With Your Team

When to Consider a Clinical Trial for Lung Cancer Treatment?


Transcript:

Katherine:

When someone is considering therapy for non-small cell lung cancer, what advice do you have for setting treatment goals with their team? 

Dr. Patil:

So, non-small cell lung cancer has seen some remarkable progress in the last 20 years, but it’s still a very serious disease. One of the main expectations I set with patients is that I will guide them through this journey, but that there’s going to be a lot of changes in their day-to-day. When we look at someone who’s receiving targeted therapy, in general I upfront tell patients that the model that I’m trying to emulate with targeted therapies is very similar to HIV. I remind patients that in 2022, we still cannot cure HIV, but we can give a very effective antiviral therapies that put their viral count to zero.  

And patients with HIV now can live really full rich lives. And that’s the model that we’re trying to replicate with targeted therapies. With immunotherapies, I set patients the expectation that immunotherapy has been a major advance in the management of lung cancer. And many patients are living very full lives as a result of using immune therapies. But it’s not for everyone, and I do enforce and or rather emphasize is a better word, the concept of taking things day-by-day. I think it’s really helpful when patients have a diagnosis like this to not spiral out of control and think about all possible future outcomes, but to really work with the data that we have at the moment.  

Questions to Ask Before Participating in a Lung Cancer Clinical Trial

Questions to Ask Before Participating in a Lung Cancer Clinical Trial from Patient Empowerment Network on Vimeo.

When considering clinical trial participation, what questions should patients ask their healthcare team? Dr. Tejas Patil, a lung cancer specialist at the University of Colorado Cancer Center, shares advice on what patients need to know when considering joining a clinical trial.

Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.

See More From Lung Cancer Clinical Trials 201

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When to Consider a Clinical Trial for Lung Cancer Treatment?

Lung Cancer Targeted Therapy: What Is It and Who Is It Right For?

Where Do Clinical Trials Fit Into a Lung Cancer Treatment Plan?


Transcript:

Katherine:

When considering clinical trial participation, what questions should patients be asking their healthcare team? 

Dr. Patil:

So, couple of questions that I think are really important for patients to ask their healthcare team is what is the current standard of care? So, if you’re enrolling in a clinical trial, you want to know that you’re receiving some kind of drug.  

And its expected effectiveness should be compared to what is considered the current standard of care for whatever line of therapy that is. The other practical questions that patients should be asking is what is the schedule of therapy? So, how frequently am I supposed to come in? Am I supposed to get a biopsy?  

Am I supposed to get blood draws? Most clinical trials will come with a schedule or a calendar for patients, and it’s helpful for them to look that over and see what’s being asked of them. And then the last thing is what are the known side effects? Now I always tell patients with a clinical trial, we don’t always know the side effects as part of the reason we’re doing the clinical trial.  

But if there’s some experience or if the doctors enrolled other similar patients in this trial asking what are the foreseeable side effects is actually really important. 

When to Consider a Clinical Trial for Lung Cancer Treatment

When to Consider a Clinical Trial for Lung Cancer Treatment from Patient Empowerment Network on Vimeo.

When it comes to non-small cell lung cancer treatment options, where do clinical trials fit in? Dr. Tejas Patil of the University of Colorado Cancer Center explains how he discusses clinical trial participation with patients.

Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.

See More From Lung Cancer Clinical Trials 201

Related Resources:

Where Do Clinical Trials Fit Into a Lung Cancer Treatment Plan?

Lung Cancer Targeted Therapy: What Is It and Who Is It Right For?

Questions to Ask Before Participating in a Lung Cancer Clinical Trial


Transcript:

Katherine:

When it comes to non-small cell lung cancer treatment options, where do clinical trials fit in? 

Dr. Patil:

So, clinical trials are very important to advancing our knowledge and advancing our ability to care for patients in the best way possible. What I frequently get asked from patients is am I going to be a guinea pig for a clinical trial? And I think it’s really important to emphasize that clinical trials are comparing the best-known standard of care to something new.  

So, in effect you would never be a guinea pig. You would really just be receiving what is the best-known standard of care. And that would be compared to some novel approach to treating cancer. In general, I’m very encouraging of patients to enroll in clinical trials.  

I discuss the pros and cons of this because there are logistical concerns to keep in mind when patients are thinking about enrolling in clinical trials. If a patient enjoys traveling, and enjoys wanting to spend time with their family, that has to be balanced against the regimented schedule that some clinical trials may have.  

If they live in a rural part of the state and they have to travel three to four hours weekly, that’s a decision that has to be had and be made. But in general, if a patient is eligible and willing, I’m strongly encouraging that patients enroll in clinical trials to help further the knowledge of the field. 

Katherine:

Yeah. Are there clinical trial options available for patients who have already been treated with another therapy? 

Dr. Patil:

Yes. So, the clinical trials come in variety of forms and patients are eligible at various stages.  

So, there are some clinical trials that require patients to be newly diagnosed. And so, the trial would be the “first therapy” that they receive. But many trials actually I would say the majority of clinical trials in lung cancer are looking at patients who’ve progressed on the first line of treatment and are now facing the possibility of receiving second line treatments or further. So, that’s a common place for patients to enroll in clinical trials. 

The Latest Lung Cancer Research Updates From ASCO 2022

The Latest Lung Cancer Research Updates From ASCO 2022 from Patient Empowerment Network on Vimeo.

Dr. Tejas Patil from the University of Colorado Cancer Center shares the latest news in lung cancer research and treatment from the 2022 American Society of Clinical Oncology (ASCO) Annual Meeting, including an update on immunotherapy.

Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.

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Transcript:

Katherine:

Researchers came together earlier this summer at the annual ASCO meeting. Were there highlights from the meeting that lung cancer patients should know about? 

Dr. Patil:

Right. So, the ASCO ’22 meeting this year had some really interesting publications. So, for me, the key publications that I thought were kind of interesting from ASCO ’22, 2022, one was a publication looking at the role of immunotherapy in patients who are – have a very high PD-L1 expression, so greater than 50 percent. And there’s – 

Katherine:

Reminds us what PDL is. 

Dr. Patil:

Oh, yes, of course. So, PD-L1 is a biomarker. It’s a predictive biomarker that lets us know whether some patients will benefit from immunotherapy. It’s also prognostic because if patients have a high PD-L1 score, they tend to do better with immunotherapy than patients who have a low PD-L1 score. 

Katherine:

Okay.  

Dr. Patil:

Now the interesting data that was presented was a pooled analysis of all the immunotherapy trials to date. And there’s been this ongoing question in lung cancer as to whether patients should get chemo with immunotherapy or whether they should just get immune therapy alone.  

And this study showed that if you have a very high PD-L1 score, it is potentially possible to just use immune therapy and forgo chemotherapy. And I thought that was a very interesting analysis.  

There’s also several other papers that came out as well. Mostly there was a lot of interest in something called circulating tumor DNA. So, let me just take a step back. This is a type of molecule that can be detected in the blood that can help determine whether cancer is present in your blood or not. And there was a lot of publications at ASCO looking at using a concept called minimal residual disease.  

So, when we treat patients with early-stage lung cancer, a big question is how do we know they’re cured or not cured? And a lot of abstracts and publications this ASCO were looking at this concept of minimal residual disease. So, if I can detect some cancer in your blood after you’ve had cured curative therapies, we’re – we have a problem because there’s still cancer around and we’re detecting it in the blood.  

And I think this type of approach is going to really inform how we think about early-stage lung cancer management in the future. 

What Testing Should Take Place After Non-Small Cell Lung Cancer Treatment?

What Testing Should Take Place After Non-Small Cell Lung Cancer Treatment? from Patient Empowerment Network on Vimeo.

It’s well-known that patients should undergo testing before choosing lung cancer therapy, but what testing should take place following treatment? Lung cancer specialist Dr. Tejas Patil, from the University of Colorado Cancer Center, discusses the role of testing after treatment.

Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.

See More From INSIST! Lung Cancer

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Why Do Lung Cancer Patients Need Molecular Testing Before Choosing Treatment?


Transcript:

Katherine:

We know that patients should undergo testing before choosing therapy, but what testing should take place following treatment? 

Dr. Patil:

That’s a really good question. And it’s a complex question depending on the type of treatment that the patient is receiving. So, broadly speaking in lung cancer, we’ve separated the field into two types of treatments.  

Patients with lung cancers will get molecular testing at the onset, right? When they’re diagnosed to look for what’s called a driver oncogene. So, these are mutations that can be targeted with pill-based treatments. And if patients have these mutations, there’s about 10 of these right now and several in development, then the patients can receive a targeted therapy.

However, if they don’t have these mutations, then the standard of care right now is some kind of chemotherapy with immunotherapy. Now, the question asked was what kind of testing do you do after diagnosis? And that really depends on which camp you’re in. So, if you’re in the targeted therapy camp, my general practice has been to repeat molecular testing upon progression. The reason is that patients who are receiving targeted therapies typically evolved some kind of resistance to targeted therapy.  

Broadly speaking, you can categorize these as on target or off target resistance, but the major reason for doing repeat molecular testing is to understand a mechanism of resistance and then hopefully develop a new treatment with that knowledge. Now for the camp that doesn’t receive targeted therapies, let’s say they receive chemotherapy and immunotherapy, there it gets a little bit more nuanced.  

And if there is a role for repeating a biopsy and looking for dynamic changes in the patient’s cancer, but it is not routine and should be done with consultation with a thoracic oncologist. And really the idea here is that if patients who are on chemo immunotherapy progress, any additional molecular testing should really help inform what the next line of treatment will be and sometimes that can be a clinical trial.  

How Does Biomarker Testing Impact Non-Small Cell Lung Cancer Care?

How Does Biomarker Testing Impact Non-Small Cell Lung Cancer Care? from Patient Empowerment Network on Vimeo.

Biomarker testing identifies certain genes, proteins, or other molecules present in a biologic sample. Dr. Tejas Patil, of University of Colorado Cancer Center, discusses how results from these tests can be used to determine a treatment approach for non-small cell lung cancer (NSCLC).

Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.

See More From INSIST! Lung Cancer

Related Resources:

Why Do Lung Cancer Patients Need Molecular Testing Before Choosing Treatment?

Lung Cancer Targeted Therapy: What Is It and Who Is It Right For?

What Testing Should Take Place After Non-Small Cell Lung Cancer Treatment?


Transcript:

Katherine:

Biomarker testing is important prior to choosing therapy for non-small cell lung cancer. What is this test and how long does it take to get results? 

Dr. Patil:

That is a great question. So, a biomarker is a biological molecule found in blood or other body fluids or tissues that is a sign of a normal or an abnormal process.  

Or let me reframe that as it represents having some kind of medical condition or disease. Now, it’s a very broad definition. Basically, a biomarker can be used to see how well the body responds to a treatment for a disease or a condition. And when we look at it from a genetic perspective, sometimes the term that you’ll see is a molecular marker or a signature molecule.  

So, these are terms that are sort of interchangeable with biomarkers. But the role of a biomarker is to help ascertain how well the body responds to a certain medical intervention, broadly speaking. 

Katherine:

Okay. What question should a patient ask their doctor about test results? 

Dr. Patil:

So that’s a very complicated question, and I will do my best to answer it succinctly. So, my personal view is that for any test to be meaningful, it should impact medical decision-making in some very concrete way.  

Specifically, with biomarkers, the result should either be prognostic or predictive and I’ll define what those terms are. So, a predictive biomarker is one that helps determine if a certain therapy will be effective. So, I’m going to use lung cancer as an example. In EGFR mutation in non-small cell lung cancer allows a doctor to prescribe an EGFR targeted therapy called osimertinib (Tagrisso). Therefore, in this example, the EGFR mutation is predictive.  

It opens the door for this targeted option that would otherwise not have been available if the patient did not have this EGFR mutation. A prognostic marker is a little different. This is the type of marker that helps categorize risk. So, in the same example I used earlier, that patient may have an EGFR mutation.  

They can also have a different mutation called TP53. Now this TP53 mutation doesn’t influence therapy. It’s not targetable, but it does influence risk.  

And so, there’s been a lot of emerging data to show that patients with TP53 mutations have worse outcomes on targeted therapies than patients without TP53. And in that case, that mutation is what we call a prognostic biomarker. 

How Can You Access Personalized Lung Cancer Treatment?

How do diagnostic tests affect your lung cancer treatment plan. Dr. Tejas Patil discusses appropriate testing for lung cancer, latest targeted therapies and how emerging research is affecting patient outcomes.

See More from INSIST! Lung Cancer

About the Guest:
Dr. Tejas Patil is an academic thoracic oncologist at the University of Colorado Cancer Center focused on targeted therapies and novel biomarkers in lung cancer. Learn more about Dr. Patil, here.


Transcript:

Katherine:

Welcome to Insist! Lung Cancer, a program focused on empowering patients to insist on better care. Today, we’ll discuss the latest advances in lung cancer, including the role of genetic testing and how this may affect treatment options.

I’m Katherine Banwell, your host for today’s program. Joining me is Dr. Tejas Patil. Dr. Patil, would you introduce yourself please?

Dr. Patil:                     

Sure. Thank you for inviting me to speak on this platform. My name is Dr. Tejas Patil. I am an Assistant Professor at the University of Colorado, where I take care of patients diagnosed with thoracic cancers, which include non-small cell lung cancer, small cell lung cancer, and also include mesothelioma and thymic cancers. My main research focus is on molecular alterations in lung cancer and development of targeted therapies.

Katherine:                  

Thank you. Before we start, a reminder that this program is not a substitute for seeking medical advice. Please refer to your own healthcare team.

Dr Patil, before we get into an in-depth discussion on lung cancer, would you tell us about the types of lung cancer?

Dr. Patil:                     

Absolutely. Lung cancer has a bit of a confusing nomenclature. Historically, Lung cancer was divided into small cell lung cancer and non-small cell lung cancer, and this distinction was based on how the lung cancer appeared under a microscope, but it also has practical implications. Small cell lung cancer tends to have a very different biology than non-small cell lung cancer. It originates from neuroendocrine cells and is treated very differently than non-small cell lung cancer.

Non-small cell lung cancer is also a bit of a misleading term because it really is a catch-all term. It represents a wide group of histologies that are not small cell lung cancer. So, basically, anything that isn’t small cell lung cancer will be non-small cell lung cancer, but that group is very heterogenous and includes subtypes like adenocarcinoma, squamous cell carcinoma, adenosquamous, large cell and even sarcoma type variance.

Distinguishing between the two is important because the prognosis and treatment options are actually very different between small cell and non-small cell lung cancer.

Katherine:                  

Well, let’s talk about testing and diagnosis. Following a diagnosis, are there specific tests that patients should ask their doctor for?

Dr.  Patil:                    

Right. After a diagnosis of lung cancer has been made, the most important next step is to establish a cancer stage, and so this is typically done through the TNM staging criteria. The T typically reflects the size of the tumor. The N reflects whether there’s lymph nodes involved with cancer and the M refers to whether there’s a metastasis, and metastasis refers to whether the cancer has spread outside of the lung.

Based on a combination of scores using the TNM criteria, lung cancers are staged from one to four. Now, to establish these different scores, oncologists will typically request varieties of scans. These include CT scans, PET CT scans, MRI and in some cases, very sophisticated ultrasound techniques called endobronchial ultrasound, so that’s the staging component. I think, in addition to the staging component, once a patient has a diagnosis of lung cancer, the tissue itself can be subject to a variety of different molecular tests which we will cover in this talk.

Katherine:                  

Well, let’s get into the tests. How are each of these tests administered?

Dr. Patil:                     

Well, first let’s discuss imaging.

Staging is a very important component of lung cancer, and at minimum, a patient should have a CT scan of the chest and abdomen with extension down to the adrenal glands. The reason for this is that this type of imaging, at least the extent of the imaging, will cover most of the metastatic sites that lung cancer tends to go towards. Additionally, a PET CT scan can be obtained.

Now, a PET scan is a very unique form of imaging. Patients will receive a radio labeled form of glucose and the principle of a PET scan is that since cancers metabolize glucose, which is sugar at a higher rate than normal tissue, the scan in principle helps clinicians identify spots where cancer could be. One important point about imaging and this is something patients should be aware of, is that lung cancers are unique cancers in that there’s a very high risk of spread to the brain.

And so, as part of baseline staging, almost every patient with lung cancer should be getting an MRI of the brain to rule out brain metastases.

Then a final point I’ll make is that patients with Stage 2 or 3 lung cancer really should have their cases reviewed in a multi-disciplinary context where there’s input from surgeons, pulmonologists, medical oncologists, and radiation specialists because the treatment for Stage 2 and 3 lung cancer can be quite complicated. I think, and we’ll talk about the – so, that was the staging part. Now, we can talk a little bit more about the diagnostic testing and molecular testing specifically.                    

There’s been tremendous advances in lung cancer. One of the biggest advances has been the appreciation that there are very specific mutations that actually “drive” cancers that cause them to grow, divide and metastasize.

We call this mutation an oncogene. Over the past two decades, there have been many oncogenes in lung cancer that have been identified. Interestingly several of these oncogenes, such as the ALK mutation, or the EGFR mutation, tend to occur in patients who were never smokers.

So, while smoking is the major environmental risk factor for lung cancer, our understanding of these, through molecular testing has identified a group of patients who were never smokers yet still developed lung cancer. The reason this is important to know is that there’s a variety of targeted therapies available for patients who do have mutations such as ALK or EGFR, and these are typically associated with very favorable outcomes in lung cancer.

Katherine:                  

What are common lung cancer mutations, first of all?

Dr. Patil:                     

There are many mutations that are found in lung cancer. I should mention that the scope of what mutations we find very much depends on the type of molecular test that’s performed. This is a topic that’s beyond the scope of this discussion, but know that when you say you are getting genetic testing, a lot of that depends on the genes that are in the test, meaning if a molecular test is only looking for 10 genes, or 10 mutations, it’s only going to pick up 10 mutations versus more comprehensive molecular testing, which look at hundreds or even thousands of genes, will identify more mutations.

That being said, there are approximately 10 mutations currently for which there are targeted therapies, either that are commercially licensed through the FDA, or are being evaluated in the context of the clinical trial.

And in patients who are heavy smokers, the most common mutation that we see that’s an oncogene is a KRAS mutation, and there’s currently drugs in clinical trials that are looking to target a very specific KRAS mutation. 

Dr. Patil:                     

In never smokers, the mutation spectrum is actually quite a bit more varied, and here, we see mutations such as ALK, EGFR, ROS1, RET, MET, HER2 and BRAF.

I want to make a quick point that there’s another biomarker that we use in lung cancer that’s not technically a mutation, per se, but it’s very important for clinicians to obtain, and that’s called a PD-L1 score. This is a score that helps clinicians decide how effective immunotherapy can be in a certain patient.

Katherine:                  

Are some mutations more common than others?

Dr. Patil:                     

Yes. I mean, there are mutations that are very common. I think to answer that question a little bit more in this cleanly, I would say that there are some mutations that are very common in lung cancer such as TP53, but these are mutations where we can’t actually, we don’t have a targeted approach to manage them. So, when I refer to common mutations, I’m talking about mutations where I either have a drug that is available and able to target the mutation, and this drug is being either investigated in a clinical trial, or is commercially licensed.

In lung cancer, the most common oncogene would be KRAS, and there, there’s a couple of exciting clinical trials where there are some promising drugs in development for treating this specific mutation which has been very challenging to treat in lung cancer.

Katherine:                  

How is genetic testing for lung cancer different from hereditary genetic testing?

Dr. Patil:                     

That’s a great question. We have learned that there are several cancers, such as breast and colorectal cancer, where there’s clear evidence that there are hereditary genes that increase an individual’s risk for developing cancer. I personally prefer the term molecular testing over genetic testing as this emphasizes that we’re looking for specific mutations that are really acquired during a patient’s lifetime and typically not inherited.

Katherine:                  

How do genetic mutations in lung cancer affect treatment options for patients?

Dr. Patil:                     

Well, the finding of a molecular alteration, or an oncogene, is really important for a patient with lung cancer because it offers a unique class of therapy that the patient would not have had otherwise. Finding a mutation is important because it allows patients to have treatment options outside of traditional chemotherapy or immunotherapy.

Katherine:                  

Dr. Patil, how do targeted therapies work?

Dr. Patil:                     

Targeted therapies are interesting. They work by specifically targeting and blocking specific mutations in lung cancer, and so it’s kind of like a lock and key model. By blocking the binding site of a mutation, the treatment actually prevents that cancer cell from properly functioning, and this in turn causes the cancer cell to be unable to divide, unable to grow, and ultimately results in cancer cell death. Targeted therapies typically come in either a form of a pill.

That’s the most common way that patients take targeted therapies.

As an aside, I will note that there’s a very unique class of targeted therapies called antibody-drug conjugates. These are really fascinating molecules. They are treatments that are consistent, but very complex, bioengineered structures, so what you have is an antibody that targets some protein on the surface of a cancer cell, a mutation.

This antibody is linked to a chemotherapy payload, and so it allows for very potent chemotherapy to be delivered effectively and selectively to cancer cells, sort of like a Trojan Horse effect where the antibody finds the cancer cell, goes inside the cancer cell, and once the whole structure is inside the cell, that’s when the chemotherapy is released.

Therefore, it’s a way of giving chemotherapy in a more targeted way, and there are several of these in clinical trials right now.

Katherine:                  

Well, you mentioned patients taking pills. What other treatment regimens are there for the targeted therapies?

Dr. Patil:                     

For targeted therapies, the most common is a pill. The schedule depends on the mutation, so it can sometimes be once a day or twice a day. And then, there are IV treatments that we see, and that is the antibody drug conjugate that I’m referring to where patients will have to go to a infusion center to get those. But to my knowledge, most of those are still in the context of a clinical trial, and so I think it’ll be a while before we start seeing them commercially licensed.

Katherine:                  

How do the newer therapies differ from the more traditional chemotherapy?

Dr. Patil:                     

Chemotherapy is still an important tool in an oncologist’s arsenal.

It works by killing, or rather it works by affecting a cancer cell’s ability to divide and grow. The logic here is that since cancer cells typically grow faster than normal cells, chemotherapy is more likely to kill cancer cells. It should be noted that while that is true, there are certain cells in the human body that grow very quickly as well, such as hair follicles, the lining of the mouth, and cells within the bone marrow. And so, as a result, it’s very common that the side effects of chemotherapy typically affect these cells, so you typically see hair loss. You see mucositis, or inflammation of the mouth, diarrhea, and low blood counts, and this a general side effect of chemotherapy.

Katherine:                  

Are there common side effects for some of the newer therapies as well?

Dr.  Patil:                    

That’s a great question and the way I’m going to answer that is it depends on the mutation that the targeted therapy’s affecting. So, a mutation that I’m going to use as an example is a mutation called EGFR. Now, this is a mutation that we see in lung cancer that causes cancer cells to grow, divide, and metastasize.

But EGFR is interesting because it also is found in normal cells, and specifically it’s found in the cells of the skin and the gut lining. This is an example where you’re giving a very targeted therapy that’s trying to attack just the cancer cell, but because normal skin cells and gut cells have this EGFR receptor, the side effects there tend to be rash and diarrhea. Now, that’s unique to EGFR. There are other drugs such as the ALK mutation or the ROS1 mutation that do not have this side effect because that specific receptor is not found in the human body.

Katherine:                  

Oh, I see. Well, how is the effectiveness of treatment monitored?

Dr. Patil:                     

Typically, I have the philosophy that patients generally know their body and can tell when symptoms are getting better or worse. So, as a guiding principle, I rely on patient input very heavily. That being said, I corroborate that experience with some testing. In my practice, I frequently use what we call serum tumor markers, so these are very nonspecific-like tests that sort of let us know if there’s cancer type proteins in the blood that we can detect while they are on targeted therapy.

And then additionally I would recommend that patients get scans frequently, at the minimum every three months if they are on targeted therapy and doing otherwise well. That includes a CT scan of the chest and abdomen, and in certain cases, an MRI of the brain, if there were brain metastases before.

Katherine:                  

Is it necessary to retest at any time?

Dr. Patil:                     

This is a good question and it’s an evolving question. In general, I strongly advocate that patients who are on targeted therapies obtain additional molecular testing after they’ve progressed, and the reason is the following. Cancer cells evolve resistance mechanisms to overcome targeted therapies and understanding these resistance mechanisms can be quite helpful in designing next lines of treatments.

A very good example of this is in EGFR lung cancer. The very first type of targeted therapy for EGFR positive lung cancer was a drug called Erlotinib. What we had seen was that when patients were on this drug, Erlotinib, they would respond, and they would do really well for a period of time.

But after a period of time, patients would progress on this therapy, and a very common mutation that we would find, once they progressed was a mutation called T790M. By biopsying this patient and finding this mutation, it was very helpful because it allowed the medical community and researchers to investigate a new drug called Osimertinib, which can overcome that resistance mutation.

And we’re learning a lot about resistance pathways and resistance mutations in lung cancer, so I think it’s very important that patients who are on targeted therapies specifically get retested and re-biopsied.

Katherine:

Let’s move on then. Dr. Patil, what are you excited about in lung cancer research right now?

Dr. Patil:                     

I thought ASCO 2020 this year was a very exciting cancer conference, and I’m very excited about where lung cancer research is going. I think there are two areas to be very hopeful about.

First, is that there have been several oncogenes or mutations that we had known about for a very long time, but there was just no targeted therapy available. I think in the next several years, you’re going to start to see more and more targeted therapies available for patients who have otherwise rare mutations.

And examples of this would include KRAS G12C, RET, Met and HER2, so this is very exciting because these were mutations that we had known about for a long time, but just until more recently really haven’t had any successful therapy for.

The other area that’s very exciting is that we’re starting to see the use of targeted therapy and immunotherapy in patients who have earlier stage cancer. So, there was a lot of talk this ASCO about using targeted therapies in patients who have, for example, Stage 3 lung cancer, and is there a benefit in doing that? I think that’s going to be a very interesting development of patients who have Stage 1 to 3, which we typically treat with curative intent, how do we make sure that they improve their outcomes and really stay cured?

Katherine:                  

Right. What would you say to patients who are nervous about participating in a clinical trial?

Dr. Patil:                     

That’s a great question. I really appreciate you asking that. In general, I would highly recommend patients consider clinical trials. I think there’s a couple of things to point out. It’s very important to remember that clinical trials are evaluating novel therapies as compared to current standard best practice. So, placebos are rarely used in cancer research unless there’s no known effective therapy. It’s important to remember, it’s not ethical to have someone take placebo if there’s known treatment that work, so when a patient enrolls in a clinical trial, sometimes they don’t know which treatment they’re getting, but at least they will know that whatever treatment they’re getting is the best current standard of care.

I want to also point out that clinical trials really answer, in my mind, two important questions. The first question is, is the new treatment safe? And does the new treatment work better than current standard of care? These are really important questions for advancing the field, especially in cancer research. Clinical trials are a small part of the research. I mean, when a drug that’s getting introduced into a clinical trial, it’s sometimes helpful to think about all the investment that has gone in before them. The drug has to be discovered, created.

It has to be purified, tested in animal studies, before it ever reaches human studies. And so, there’s only the most promising agents are actually ever introduced at clinical trials, and there’s a lot of data to show that the biggest barrier for completing clinical trials, and therefore understanding which treatments are effective, is really participant enrollment.

I think there was a recent study that showed that about, I think less than five percent of patients, less than 1 in 20, with cancer will ever take part in a clinical trial, Therefore, if a patient has that opportunity, I would strongly encourage them to consider it.  

Katherine:                  

Do you think a second opinion is necessary? Would you encourage patients to consult with another specialist?

Dr. Patil:                     

In general, I’m a big advocate that patients should get all the information they need to make informed treatment decisions, and if that involves getting second opinions, I welcome that.

 I think that a knowledgeable patient is an empowered patient, and certainly a knowledgeable patient is one that I think will be able to guide themselves through a very complex medical journey. So, in general my philosophy is I’m always encouraging of second opinions if the patient feels that they need more information to make a best decision.    

Katherine:                  

What advice do you have for patients who may be hesitant to speak up and advocate for themselves when it comes to their care and treatment?

Dr. Patil:                     

Great question. In general, I’m a big believer that an empowered patient is a patient that can make really good medical decisions as they navigate their own medical journey. Ultimately, it’s important for patients to be knowledgeable and seek multiple opinions. Really get the best advice, so that they make the best decisions. Oncology is a very complicated field. The treatment options can be very nuanced.

Therefore, it’s important to know that when a decision is presented to a patient, that it is a decision that is made with the knowledge of what is the best standard of care. But if the patient doesn’t feel like they have the most informed data to guide their own medical decision making, then it’s really important for them to advocate for themselves.

To that point, especially for some of these rarer mutations, there are many social media patient advocacy groups that are very, very, very well organized, very effective, and have a list of really useful questions. Some examples of that are the ALK Positives and the EGFR Resisters.

Katherine:                  

Okay. I would be remiss if we didn’t discuss COVID-19 to some extent. What should lung cancer patients be considering at this time?

Dr. Patil:                     

This is also a very important and timely question. lung cancer patients are certainly at very high risk of complications from COVID-19. And it’s understandable, especially given the kinds of treatments that patients with lung cancer receive, that there’s a lot of them will wind up having compromised immunity which makes them at increased risk for adverse outcomes from COVID-19. That being said, I think it’s really important that this be balanced with the actual risk of untreated or inadequately treated lung cancer, which is also a major medical concern. What I tell patients is that, at least at our institution, we do everything we can to create an environment that is as safe as possible from a COVID mitigation standpoint.

But at the end of the day, untreated lung cancer can have a very aggressive course, and so making sure that patients understand that as we try to move things to a more telemedicine type approach, that there are some things where you really just have to come and see your doctor. Not everything can be done virtually.

Katherine:                  

Right, and my next question was is telemedicine the best approach right now?

Dr. Patil:                     

Well, that’s also, I’m going to answer that in a somewhat frustrating way, which is that there’s – yes and no. I think telemedicine is helpful for patients who have very stable disease and are on anti-cancer treatment, so specifically a patient on targeted therapy, for example.

A pill once a day. Their last scans show that they’re doing really well. They feel well. They’re exercising every day. That patient, probably we can do a visit virtually and just make sure and check in that there’s nothing new or concerning that’s come up.

The other patient that probably I can see a role for telemedicine is someone who had, let’s say, a Stage 1 lung cancer that was treated with surgery, and we’re just monitoring them on surveillance. That patient probably doesn’t have to come into the clinic to see us. But in general, the thing about lung cancer is that most patients are getting some kind of chemotherapy or immunotherapy and will be coming into an infusion center, and so what I would tell patients is if there’s any new or concerning symptoms, to a very low threshold for seeking an in-person evaluation.

Katherine:                  

As a researcher in this field, Dr. Patil, what do you want to leave the audience with? Are you hopeful?

Dr. Patil:                     

I’m very hopeful. I think, it’s kind of amazing when I look at the history of lung cancer and where the field was in the 2000s, now that we’re in 2020, and what remarkable advances have been made in 20 years. It’s worth reminding patients that in 2000, there was, platinum chemotherapy was the first line for metastatic lung cancer, and then there was a second line chemotherapy and that was basically it. Now we’re in an era where we have extensive molecular testing of lung cancer. We’re identifying new mutations that can be targeted with very sophisticated pill-based therapies. We have immunotherapy. We’re learning about how these combine with each other to produce the most optimal outcomes, so I think in 20 years a lot has been achieved, and I’m really excited to see where we go from here.

Katherine:                  

Dr. Patil, thank you so much for joining us today.

Dr. Patil:                     

Thank you. Thank you for inviting me. This was wonderful.

Katherine:

And thank you to all of our partners.

To learn more about lung cancer, and to access tools to help you become a more proactive patient, visit www.powerfulpatients.org. I’m Katherine Banwell.  

MPN Terms Defined: What is Leukocytosis? What is Anemia?

MPN Terms Defined: What is Leukocytosis? What is Anemia? from Patient Empowerment Network on Vimeo.

Physician assistant, Lindsey Lyle, provides definitions for leukocytosis and MPN-related anemia, both commonly used terms when discussing myeloproliferative neoplasms (MPNs).

Lindsey Lyle is a physician assistant at the University of Colorado Cancer Center, specializing in hematological malignancies with a subspecialty in myeloproliferative neoplasms (MPNs). More about this expert here.

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Transcript:

Lindsey:

There are a few terms that often come up. No. 1 is “leukocytosis.” This often is a term that’s thrown around, especially in relation to myelofibrosis and also polycythemia vera, and this term means an elevated white blood cell count. That is a common thing that, as medical providers, we may just throw around in the room and not necessarily think about the fact that we should explain that a little bit better.

Additionally, “anemia” is a term very often used when talking about myelofibrosis, and that just means a decrease in red blood cells.

Often, people associate anemia with iron deficiency because this is probably the most common form of anemia, but as it relates to MPNs – and specifically, myelofibrosis – it is generally a problem with production that does not have anything to do with iron, but is actually more so just related to the disease and how the red blood cells are impaired because of the fibrosis of the bone marrow.

Could an MPN Clinical Trial Be Your Best Treatment Option?

Could an MPN Clinical Trial Be Your Best Treatment Option? from Patient Empowerment Network on Vimeo.

Lindsey Lyle discusses the role of clinical trials as an MPN treatment option and how research is advancing the field.

Lindsey Lyle is a physician assistant at the University of Colorado Cancer Center, specializing in hematological malignancies with a subspecialty in myeloproliferative neoplasms (MPNs). More about this expert here.

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Transcript:

Lindsey:

When considering treatment, remembering that clinical trials are an option – and often, a very good choice – is something that I really try to communicate to my patients. Generally, there’s a stigma around clinical trials as patients feeling like a lab rat or some sort of a study subject, and there is a perception that they’re not receiving as good of care as they would if they were not on a clinical trial. However, in my patients, I really try to dismiss this thinking because at this point in time, we do have really fairly good options for treatments with MPNs.

However, we do not have a cure for MPNs outside of a transplant, and our treatments are not perfect, and so, enrolling in a clinical trial really should be considered by patients and their providers as a very viable option.

It’s generally introducing perhaps a new way of approaching the disease treatment. Oftentimes, clinical trials are using a combination of agents, which is not necessarily available outside of the clinical trial.

And so, with clinical trials, we’re always trying to make something better. We’re trying to learn something, we’re trying to, No. 1, help the patient – so, my No. 1 goal in enrolling one of my patients in a clinical trial is to, first of all, help them, help control their disease, help them to feel better, and to live a long and good life. No. 2, we learn as we go along. Clinical trials are critical for drug development and for the future of treatment in patients with MPNs.

So, not only are our patients helping themselves, but hopefully, they are helping the future MPN patients who may come along and need a treatment. So, I always like to keep this really in the conversation when discussing treatments, and it may be up front, and it also may be after a treatment has stopped working that we consider a clinical trial.

So, there are also a lot of things that kind of go into clinical trial management and different requirements, so if a patient lives very far away, it may be challenging for them to come back to the academic center on a regular basis for routine clinical trial monitoring that’s required by the study, but if they live close by, I generally do recommend this. They are also associated with clinical research coordinators or clinical trial nurses.

And, these patients are monitored really very closely, and it’s kind of nice to have that extra person in it with you in the clinical trial, just another point person to discuss, perhaps, how you’re feeling or different questions or concerns as the clinical trial proceeds. So, when talking about treatments, in my opinion, especially in MPNs, clinical trials really should be one of the options that is first discussed when thinking about starting treatment, and especially if a treatment has stopped working.

So, there are very many exciting possibilities in MPN research right now. We have a lot of combination therapies, which I think I am most excited about, because we have a decent backbone of therapy at this point, but building on that and trying to maybe enhance the way that the backbone therapy works, and also to perhaps change the microenvironment of the bone marrow – basically, trying to reverse fibrosis.

So, there is currently a drug in clinical trial that is looking at this, and we are proceeding with this trial, and really hoping for the best, but I think that to combination therapies where we can put two things together that we think work really well together to help produce good outcomes – I think I’m most excited about that at this point.

Ready to Start an MPN Treatment? What You Need to Consider.

Ready to Start an MPN Treatment? What You Need to Consider. from Patient Empowerment Network on Vimeo.

Lindsey Lyle discusses the factors that should be considered when choosing a therapy.

Lindsey Lyle is a physician assistant at the University of Colorado Cancer Center, specializing in hematological malignancies with a subspecialty in myeloproliferative neoplasms (MPNs). More about this expert here.

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Transcript:

Lindsey:

When deciding about a treatment, it’s really important for the healthcare professional and the patient to discuss the patient’s goals.

The patient really is the key player here, and we as medical professionals are here to support the patient’s goals. So, what might work for one patient is not going to be necessarily the same treatment I would choose for a different patient. So, right off the bat, identifying the patient’s goals – and really, what are we trying to fix in one specific patient is going to look different from the next patient I see in that day.

For example, there are certain clinical manifestations of MPNs that need specific treatment approaches and maybe honing in on trying to help one clinical issue.

So, first of all, identifying the disease process – that’s No. 1. What is the diagnosis? No. 2: Coming up with a goals of care plan with the patient. What is causing them the most difficulty in their everyday life, and how are we going to fix that? That’s generally where I start.

Then, I discuss with the patients the different options for treatment, which either include therapies that are FDA-approved or enrolling in a clinical trial. And then, we really talk about pluses and minuses for each of these therapeutic decisions.

Patients may have different comorbidities, so they may suffer from different chronic diseases that may impact the treatment that is chosen with the patient and their provider, as well as discussing stem cell transplant, which we haven’t talked much about, but stem cell transplant is an option, and at this point, the only curative therapy for patients with myelofibrosis. And so, determining whether or not transplant is in the patient’s best interest is also a topic of discussion when deciding on therapy approach.

Essential Lab Tests for Myeloproliferative Neoplasm (MPN) Patients

Essential Lab Tests for Myeloproliferative Neoplasm (MPN) Patients from Patient Empowerment Network on Vimeo.

 Lindsey Lyle, a physician assistant specializing in MPNs, reviews the lab tests that should be administered following an MPN diagnosis and how the results could affect overall care.

Lindsey Lyle is a physician assistant at the University of Colorado Cancer Center, specializing in hematological malignancies with a subspecialty in myeloproliferative neoplasms (MPNs). More about this expert here.

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Transcript:

Lindsey:

When somebody is diagnosed with an MPN, there are a variety of tests that are important for coming up with treatment strategies. And so, really, before starting treatment, it’s fairly imperative to have a CBC, or complete blood count, which was very likely done that led to the diagnosis of the MPN, but that’s very critical, as well as having a differential. This is basically just looking a little bit deeper at the white blood cells and their components, so that’s a critical part of the CBC, or complete blood count.

And then, having a chemistry panel, just to look at organ functioning, such as the kidney functioning and the liver functioning, as well as different electrolytes that may be indicative of something going on that would maybe impact treatment.

Additionally, having a bone marrow biopsy with molecular testing is advised. This is very critical in leading to the diagnosis of the MPN and then, also, really differentiating what subtype of MPN a patient may have.

The bone marrow is very critical for this purpose, and the genetic testing helps us to understand perhaps if a patient is having a higher-risk disease or a lower-risk disease and can help guide treatment as well. There are a variety of other chemistry tests that are done that can help specifically when looking at patients with polycythemia vera. This may be called an erythropoietin level.

Additionally, iron studies are generally recommended before starting treatment for MPNs, just to assess iron storage, availability, and that sort of component to the treatment may vary depending on that result. Additionally, if patients are having any sort of symptoms related to an enlarged spleen, generally, having an imaging study may be warranted if the symptom is quite severe and causing problems, and getting a baseline prior to starting treatment is generally a good idea.

When looking at a CBC, there are really three main cell lines that we monitor closely in MPNs regardless of the subtype, and this includes the white blood cell count, the red blood cell count or hemoglobin and hematocrit – those are measures of the total red blood cell count – and then, also, platelets. And so, these really are three different types of cells that your bone marrow produces that help with different functions.

And so, monitoring for any sort of changes within these three cell lines – white blood cells, red blood cells, or platelets – can really help us know maybe how the disease is changing, how a patient is responding to treatment, so these three key laboratory values are very necessary and really help us as providers and U.S. patients monitor progress, or for any changes in a positive way, or perhaps in a way that needs to be addressed.

Diagnosed With an MPN? Why You Should Consider a Second Opinion.

Diagnosed With an MPN? Why You Should Consider a Second Opinion. from Patient Empowerment Network on Vimeo

 Physician assistant Lindsey Lyle explains the importance of seeking a second opinion when diagnosed with an MPN.

Lindsey Lyle is a physician assistant at the University of Colorado Cancer Center, specializing in hematological malignancies with a subspecialty in myeloproliferative neoplasms (MPNs). More about this expert here.

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Transcript:

Lindsey:

When a patient is initially diagnosed with an MPN, seeking a second opinion is generally a very good idea, especially if patients are perhaps in an area where they do not have access to academic medical center.

The reason is that MPNs are such a small percentage of blood cancers – and, blood cancers in and of themselves are very rare, so MPNs are very rare, and especially in rural places, physicians do not have access or experience so much with MPNs. So, especially in those scenarios, I always advise a second opinion.

However, even within the academic medicine world, for example, if a patient is referred to me by their primary care physician or our institution, we always offer patients to seek a second opinion. Really, this is to gather information and either encourage the patient because the recommendation is the same or also to perhaps have a different idea for treatment that may fit the goals of the patient better, and so, I’m always telling patients to seek second opinions.

An Expert Summary of Current MPN Treatment Options

An Expert Summary of Current MPN Treatment Options from Patient Empowerment Network on Vimeo.

 MPN expert, Lindsey Lyle, provides an overview of therapies used to treat myelofibrosis (MF), polycythemia vera (PV) and essential thrombocythemia (ET).

Lindsey Lyle is a physician assistant at the University of Colorado Cancer Center, specializing in hematological malignancies with a subspecialty in myeloproliferative neoplasms (MPNs). More about this expert here.

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Transcript:

Lindsey:

To overview the treatment types for MPNs, we have a variety of different mechanisms in which we use, and clumping these three main MPNs together, we can kind of break it down into, first of all, cytoreductive therapy, which is nonspecific, but really just reduces the amount of cells the bone marrow is producing. And so, it’s really to control the blood counts. And, different types of cytoreductive therapy generally are – hydroxyurea is used probably the most commonly.

There are some other sorts of chemotherapy that may be used in different instances. We also have biological agents, such as interferons, that may be used in patients with MPNs. We then have JAK inhibitors, which there are two FDA-approved JAK inhibitors at this point for myelofibrosis, and one approved for polycythemia vera.

We also have a variety of novel agents in clinical trials. These may be inhibiting different pathways of the cellular production or different signaling pathways at the level of the stem cell, so there are a variety of those. We also use hypomethylating agents in some patients who maybe have higher-risk disease, mainly myelofibrosis, that really changes the way that the stem cells are produced in the bone marrow in order to control the cell counts and also symptoms.

So, there are a variety of therapeutic measures that are taken. Additionally, not necessarily medication-related, but phlebotomy, which is considered a therapy for polycythemia vera, is generally used in order to reduce red blood cell volume, and then, aspirin is commonly used, especially in polycythemia vera and essential thrombocythemia as a supportive care medication to reduce risk of complications from the disease.