Hematology Oncology News: IMRT new standard of care for high-risk cervical cancer: https://bit.ly/3k7ji3y Real-world results with checkpoint inhibitors found inferior to trial results: https://bit.ly/35cIt0v Are HMAS appropriate for posttransplant maintenance in acute leukemias?: https://bit.ly/3lfqsE7 You can email the show at email@example.com.
In this episode, we review how PD-L1 inhibitors and COVID-19 have changed the management of non-small cell lung cancer (NSCLC). Jeffrey Crawford, MD, and Susan Blackwell, PA, both of Duke Cancer Institute, join host David H. Henry, MD, to discuss the use of pembrolizumab in NSCLC, two studies of PD-L1 inhibitors presented at ESMO 2020, and how COVID-19 has affected NSCLC care, particularly the use of granulocyte colony-stimulating factor (G-CSF). Diagnosis and treatment of NSCLC What information should be obtained from a biopsy? Is this lung cancer? If so, what kind of lung cancer is it: Small-cell lung cancer or NSCLC? Which subtype? Molecular studies for targets, including ALK, KRAS, EGFR, PD-L1. Treatment with pembrolizumab: If, for example, a patient has NSCLC and is positive for PD-L1, the treatment of choice is pembrolizumab. A multidisciplinary approach is essential to provide comprehensive education and care to patients taking pembrolizumab (and other immunotherapies). Pembrolizumab can have many side effects, including itching, fatigue, thyroiditis progressing to hypothyroidism, hypophysitis, or another off-target “-itis.” Ms. Blackwell and Dr. Crawford recommend listening to patients, checking the thyroid routinely, and checking cortisol based on index of suspicion. NSCLC studies presented at ESMO 2020 KEYNOTE-024 5-year OS update: First-line (1L) pembrolizumab (pembro) vs platinum-based chemotherapy (chemo) in patients (pts) with metastatic NSCLC and PD-L1 tumour proportion score (TPS) ≥50%. The 5-year survival is greater than 30% with pembrolizumab in this study. Historically, 5-year survival has been 1% to 2% in patients treated with chemotherapy alone, Dr. Crawford said. In the control arm of this study, patients received chemotherapy and then crossed over into the pembrolizumab arm, so overall survival was 16% at the 5-year mark. The results suggest immunotherapy should be used first-line if patients meet criteria, Dr. Crawford said. Source: Abstract LBA51. https://bit.ly/3mMYLTK. EMPOWER-Lung 1: Phase III first-line (1L) cemiplimab monotherapy vs platinum-doublet chemotherapy (chemo) in advanced non-small cell lung cancer (NSCLC) with programmed cell death-ligand 1 (PD-L1) ≥50%. The PD-L1 inhibitor cemiplimab improved overall and progression-free survival in NSCLC patients when compared with chemotherapy alone. Abstract LBA52. https://bit.ly/3mLT6xb. The effects of COVID-19 on NSCLC care Logistically, it’s more difficult to see patients during the pandemic, Dr. Crawford noted, but the many potential side effects of immunotherapy make it necessary to see patients regularly in person. How has COVID-19 affected the concern of febrile neutropenia and the use of G-CSF? Dr. Crawford said the pandemic has heightened the concern about infection risk. Prior guidelines for G-CSF: Before the pandemic, guidelines suggested routine prophylactic G-CSF in patients with a greater than 20% risk of febrile neutropenia. In patients with 10% to 20% risk, the recommendation was to consider the use of G-CSF based on the patient population and risk factors. Pandemic-specific guidelines for G-CSF: The National Comprehensive Cancer Network (NCCN) recommended relaxing guidelines during the pandemic. If the risk is greater than 20%, NCCN still recommends giving G-CSF. If the risk is 10% to 20%, NCCN recommends giving G-CSF even in the absence of additional risk factors. Dr. Crawford noted that lung cancer patients receiving chemotherapy are typically in the 10% to 20% risk category. Download the COVID-specific NCCN guidelines: https://bit.ly/3jQIco5. G-CSF biosimilars The most common complaint with biosimilars is bone pain. Ms. Blackwell advises first treating bone pain with acetaminophen or ibuprofen and warm blankets. For refractory pain, she suggests a low-dose narcotic or dexamethasone. Consider an antihistamine for prophylaxis, as patients report this can help with symptoms. Show notes written by Ronak Mistry, DO, a resident at Pennsylvania Hospital, Philadelphia. Disclosures: Dr. Crawford is on advisory boards at Amgen and Merck, makers of Onpro/Neulasta (pegfilgrastim) and Keytruda (pembrolizumab). Ms. Blackwell and Dr. Henry have no conflicts of interest. * * * For more MDedge podcasts, go to mdedge.com/podcasts Email the show: firstname.lastname@example.org Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd
News from MDedge Hematology-Oncology: New estimates for breast cancer risk with HRT: https://bit.ly/37VT0Pt BMJ study: https://bit.ly/2TKDIVt Lancet meta-analysis: https://bit.ly/3kUdbRl Single and multifraction SBRT found comparable for lung metastases: https://bit.ly/2HS36pR Statins may lower risk of colorectal cancer: https://bit.ly/3kLbR37 Email Blood & Cancer at email@example.com. Follow us on Twitter @MDedgeHemOnc.
How to use antiemetics: Dr. Paul Hesketh reviews ASCO’s guidelines on antiemetic use in cancer patients receiving checkpoint inhibitors or antineoplastic agents
In this episode, we review the latest guidelines on antiemetics from the American Society of Clinical Oncology (ASCO). Host David H. Henry, MD, is joined by ASCO guideline author Paul J. Hesketh, MD, of Lahey Hospital and Medical Center in Burlington, Mass. Dr. Hesketh explains the recommendations for antiemetic use in cancer patients receiving checkpoint inhibitors (CPIs) or high-, moderate-, or low-emetic-risk antineoplastic agents. Checkpoint inhibitors The update to ASCO’s guidelines was primarily driven by questions about antiemetic use in patients receiving CPIs, according to Dr. Hesketh. After a literature review, Dr. Hesketh and coauthors concluded that: Patients receiving CPIs alone do not require an antiemetic regimen. When CPIs are given with chemotherapy, there is no need to modify the antiemetic regimen. Dexamethasone does not compromise the efficacy of CPIs. High-emetic-risk antineoplastic agents Adults treated with cisplatin and other high-emetic-risk single agents should be offered a four-drug combination: an NK1 receptor antagonist, a serotonin (5-HT3) receptor antagonist, dexamethasone, and olanzapine on day 1. Dexamethasone and olanzapine should be continued on days 2-4, as cisplatin can cause delayed emesis. Adults treated with an anthracycline plus cyclophosphamide should be offered a four-drug combination: an NK1 receptor antagonist, a 5-HT3 receptor antagonist, dexamethasone, and olanzapine on day 1. Unlike with cisplatin, only olanzapine should be continued on days 2-4. Olanzapine is an effective antiemetic in a number of settings, Dr. Hesketh said. For example, olanzapine is useful in the setting of hematopoietic stem cell transplant. A 5-mg dose of olanzapine has proven effective and may be better tolerated than a 10-mg dose. Moderate-emetic-risk antineoplastic agents Adults treated with higher-dose carboplatin (area under the curve ≥4 mg/mL per min) should be offered a three-drug combination: an NK1 receptor antagonist, a 5-HT3 receptor antagonist, and dexamethasone on day 1. Adults treated with moderate-emetic-risk antineoplastic agents (excluding higher-dose carboplatin) should be offered a two-drug combination: a 5-HT3 receptor antagonist and dexamethasone on day 1. Adults treated with cyclophosphamide, doxorubicin, oxaliplatin, and other moderate-emetic-risk antineoplastic agents known to cause delayed nausea and vomiting may be offered dexamethasone on days 2-3. Low-emetic-risk antineoplastic agents Adults treated with low-emetic-risk antineoplastic agents (e.g., fluorouracil, gemcitabine) should be offered a single dose of a 5-HT3 receptor antagonist or a single 8-mg dose of dexamethasone before antineoplastic treatment. Cannabinoids There is no good data on the use of cannabinoids, apart from those cannabinoids approved by the Food and Drug Administration, according to Dr. Hesketh. The ASCO guidelines state: There is insufficient evidence to make a recommendation regarding medical marijuana to prevent nausea and vomiting in cancer patients receiving chemotherapy or radiation. Similarly, there is insufficient evidence to make a recommendation on the use of medical marijuana in place of the approved cannabinoids dronabinol and nabilone for the treatment of nausea and vomiting in cancer patients receiving chemotherapy or radiation. SOURCE: Hesketh PJ et al. J Clin Oncol. 2020 Aug 20;38(24):2782-97. https://bit.ly/3oxahUP Show notes written by Alesha Levenson, MD, a resident at Pennsylvania Hospital, Philadelphia. Disclosures: Dr. Hesketh disclosed institutional research funding from AstraZeneca and F. Hoffmann-La Roche. Dr. Henry has no relevant disclosures. * * * For information on the negative effects of marijuana, listen to our sister podcast, Psychcast, on MDedge (https://bit.ly/3mBM6TB), Spotify (https://spoti.fi/3mwVvvn), or wherever you get your podcasts. * * * For more MDedge Podcasts, go to mdedge.com/podcasts. Email the show: firstname.lastname@example.org. Interact with us on Twitter: @MDedgehemonc. David Henry on Twitter: @davidhenrymd.
Patients will gain access to clinical notes, lung cancer screening guidelines fall short, and AML standard remains elusive
Hematology-Oncology News: National lung cancer screening guidelines may miss younger African American individuals at high risk: https://bit.ly/3e2CmhV Standard treatment lacking in relapsed / refractory AML: https://bit.ly/3kzoUVh (03:08) Patients can read your clinical notes starting Nov. 2: https://bit.ly/3mnuudL (05:40) Update: The deadline for "open notes" has been extended to April 5, 2021. You can email the show at email@example.com.
Hematology case review: Suspected ITP, presumed heparin-induced thrombocytopenia, and an ‘interesting’ case of anemia
In this episode, we review three hematology cases. One case illustrates the work-up and treatment of immune thrombocytopenia (ITP). Another case demonstrates how to diagnose and manage heparin-induced thrombocytopenia (HIT). And the final case is a patient who presented with anemia, a new mitral valve murmur, and mild splenomegaly. Host David H. Henry, MD, reviews these cases with three residents from Pennsylvania Hospital in Philadelphia – Sheila De Young, DO; Ronak Mistry, DO; and Debika Shinohara, MD, PhD. Case 1: Suspected ITP with Sheila De Young, DO Patient presentation: A 50-year-old female with no past medical history and incidental platelet count of 4,000/microL (normal 150,000-450,000/microL [150-450 x 109/L]). On physical exam, there was no lymphadenopathy, and the spleen was nonpalpable. She had obvious petechiae on her legs. A urine pregnancy test was negative. Her hemoglobin and white blood cell counts were normal via complete blood count. ITP definition: Acquired thrombocytopenia caused by autoantibodies against platelet antigens. One of the most common causes of thrombocytopenia in otherwise asymptomatic adults. To consider: Increased destruction, decreased production, and pseudothrombocytopenia To ensure the platelet count is not falsely low (in the case of pseudothrombocytopenia), looking at a peripheral smear is helpful. If red blood cells and white blood cells appear normal, we can exclude pseudothrombocytopenia. Work-up: We need to rule out secondary causes of thrombocytopenia such as HIV, hepatitis C, chronic lymphocytic leukemia, systemic lupus erythematosus, etc. Management/treatment: In the acute setting, the treatment for ITP is intravenous immunoglobulin and steroids. Long-term management of ITP includes steroids, splenectomy, thrombopoietin receptor agonists (romiplostim/eltrombopag), and rituximab. Case conclusion: This patient was found to have ITP. Shared decision-making led to the patient receiving a thrombopoietin receptor. Case 2: Possible HIT with Ronak Mistry, DO Patient presentation: A male with ischemic leg and creatinine phosphokinase greater than 4,000 units/L. His platelet count was 101,000/microL on admission, 70,000/microL on the second day, and 60,000/microL on the third day. The patient was on prophylactic subcutaneous heparin for 48 hours, so the surgery team considered HIT to explain the drop in platelets. HIT definition: A life-threatening complication of exposure to heparin. Results from autoantibody directed against endogenous platelet factor 4 (PF4) in complex with heparin. To consider: Determine baseline platelet count, what type of heparin the patient received, and look at when the heparin was administered in relation to when the platelet count dropped. HIT is far less common in patients who receive subcutaneous heparin versus intravenous heparin. Typically, we see a 50% decrease in platelet count 5-10 days following exposure to heparin. Work-up: In the inpatient setting, it is important to consider other causes that predispose patients to thrombocytopenia (i.e., critical illness, medications). Thrombocytopenia can represent a consumptive process of platelets secondary to tissue injury in the setting of elevated creatine phosphokinase. Diagnosis: Enzyme-linked immunosorbent assays (ELISAs) can detect the presence of PF4-heparin antibody. ELISA should be followed by a confirmatory test. The serotonin release assay is preferred among diagnostic tests for HIT. Management/treatment: Stop heparin immediately. Giving more platelets is not the solution. It increases a person’s risk for thrombotic events. The patient needs to be placed on different anticoagulation, such as argatroban or fondaparinux, to carry them through this procoagulant time frame. Case conclusion: HIT was ruled out in this patient. Case 3: Anemia case with Debika Shinohara, MD, PhD Patient presentation: A female, age 45 years, with a 4-month history of intermittent fevers and unintentional weight loss. Her hemoglobin was 8 g/dL, but she had otherwise unremarkable blood work. On physical exam, she was found to have a new mitral valve murmur and mild splenomegaly. To consider: Increased destruction versus decreased production of red blood cells. Low reticulocyte count ( Work-up: Test vitamin B12, folate, and iron (ferritin, transferrin saturation, and total iron-binding capacity). Elevated transferrin is characteristic of anemia of chronic disease/inflammation. Peripheral smear: The red blood cells are normocytic and normochromic in most cases of anemia of inflammation. In the setting of elevated transferrin, new-onset murmur, and fever of unknown etiology, it is important to do infectious work-up with blood cultures and cardiac ECG to rule out infective endocarditis. Infective endocarditis: Systemic manifestations include Janeway lesions, Roth spots, and Osler nodes. Infection with Streptococcus bovis indicates a need for workup of colon cancer. Case conclusion: Blood cultures came back positive for viridans streptococci. The patient was found to have a left atrial myxoma, which was likely the nidus of infection that had seeded the bloodstream. The patient was started on intravenous antibiotics and seen by cardiothoracic surgery to remove the myxoma. Show notes written by Alesha Levenson, MD, a resident at Pennsylvania Hospital. Disclosures: All participants in this episode have no relevant financial disclosures. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: firstname.lastname@example.org Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd
Choosing surgery for older breast cancer patients, delayed screening from COVID-19 could increase deaths, and blood group O linked to decreased SARS-CoV-2 risk
Hematology Oncology News: Study advances personalized treatment for older breast cancer patients (https://bit.ly/3dHieSk) Delayed cancer screening could cause increase in deaths, study says (https://bit.ly/34afIAS) Blood group O linked to decreased risk of SARS-CoV-2 infection (https://bit.ly/2T8qilF) Email Blood & Cancer at email@example.com or follow us on Twitter @MDedgeHemOnc.
TERAVOLT registry sheds light on characteristics, treatment, and outcomes of patients with thoracic cancers and COVID-19
How do patients with thoracic cancers fare when they develop COVID-19? The researchers behind the TERAVOLT registry are trying to find out. TERAVOLT investigator Alessio Cortellini, MD, of the University of L’Aquila (Italy), joined host David Henry, MD, to discuss the TERAVOLT registry and its findings, which were recently presented at the European Society for Medical Oncology Virtual Congress 2020. What is TERAVOLT? TERAVOLT is an international registry of patients with thoracic cancers and COVID-19 that was launched in March 2020 by Marina Garassino, MD, of the National Cancer Institute of Milan. The registry enrolls patients with any solid thoracic cancer – small cell and non–small cell lung cancer, mesothelioma, thymic epithelial tumors, and other pulmonary neuroendocrine neoplasms. Patients are deemed to have COVID-19 if they test positive by reverse transcription–polymerase chain reaction or serology or if they have radiologic or clinical characteristics of COVID-19 and known interaction with a COVID-positive person. TERAVOLT website: http://teravolt-consortium.org/ TERAVOLT data at ESMO 2020 Data presented at ESMO 2020 included 1,012 patients from 20 countries, mostly in Europe (74%) and North America (23%). The data encompass patient characteristics, oncologic treatment and COVID-directed therapy, and outcomes. In all, 32% of patients died of COVID-19. A multivariable model revealed several factors associated with an increased risk of mortality, including: Eastern Cooperative Oncology Group (ECOG) performance status of 2 or greater (odds ratio, 3.6; P Stage IV cancer (OR, 1.9; P Former or current smoker (OR, 1.8; P Prior steroid use (OR, 1.7; P Age 65 years or older (OR, 1.5; P = .01) Receiving chemotherapy or no systemic treatment versus immunotherapy, chemoimmunotherapy, or targeted therapy (OR, 1.4; P = .03) Espinar JB et al. ESMO 2020, Abstract LBA75. https://bit.ly/371aGIJ A tool to predict mortality Based on their findings, TERAVOLT researchers developed a nomogram that can help predict mortality in patients with thoracic cancers and COVID-19. Patients receive points based on ECOG performance status, cancer stage, smoking habits, age, steroid use, and systemic cancer treatment. For example, a 70-year-old smoker with an ECOG score of 2 who is receiving third-line treatment with docetaxel for stage IV squamous non–small cell lung cancer would have a score of 260 points, which translates to a greater than 60% risk of death. A 50-year-old never-smoker with an ECOG score of 0 who is receiving first-line osimertinib for stage IV non–small cell lung cancer would have a score of 55 points, which translates to a less than 20% risk of death. Disclosures: Dr. Cortellini and Dr. Henry have no financial disclosures relevant to this episode. * * * For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: firstname.lastname@example.org Interact with us on Twitter: @MDedgehemonc David Henry on Twitter: @davidhenrymd
FDA approves combo immunotherapy for mesothelioma, atezolizumab strikes out in ovarian cancer, and more
Hematology-Oncology News: Radiotherapy planning scans reveal breast cancer patients’ CVD risk (https://bit.ly/2FeoJiH) FDA OKs combination immunotherapy for first-line mesothelioma treatment (https://bit.ly/2Ff77mS) Apatinib plus gefitinib: Better PFS but more toxicity (https://bit.ly/34IyVsn) Atezolizumab strikes out in ovarian cancer (https://bit.ly/3iPjXG1) Email Blood & Cancer at email@example.com and learn more at https://www.mdedge.com/podcasts/blood-cancer
Lorenzo Norris, MD, host of Psychcast, joins Blood & Cancer host David Henry, MD, to discuss steps clinicians can take to alleviate the distress associated with receiving a diagnosis of cancer. Dr. Norris is director of consult liaison psychiatry at George Washington University, Washington. Dr. Henry is clinical professor of medicine at the University of Pennsylvania, Philadelphia. Both doctors have no disclosures. A full transcript of this episode is available here: A conversation on mental health and cancer https://bit.ly/2Fgat9k Take-home points Cancer patients have always been susceptible to developing depression and anxiety after receiving their distressing diagnoses. During the COVID-19 pandemic, the risk for depression and anxiety are even greater because patients face separation from their oncology treatment teams and for some, delays in treatment. Major depressive disorder (MDD) occurs in up to one-third of cancer patients, and any depressive disorder can be seen in about half. Another concern is how to screen for depression in the context of cancer. Dr. Norris suggests using the Patient Health Questionnaire–2 (PHQ-2) screener, or the question: “Are you sad or depressed?” Answering those questions can give patients the opportunity to open up about their emotions. Signs of depression in cancer include nonadherence to treatment, changes in mood and anxiety affecting daily functioning at home or work, and demoralization, which is defined as helplessness, isolation, and despair in the face of overwhelming stressors. Summary An emotional upset, such as disbelief, despair, or even denial, might occur immediately after receiving a cancer diagnosis. A depressive disorder, however, is a persistently depressed, sad mood with changes in functioning that affect the patient, his/her family, and even engagement with treatment. Findings of studies about the prevalence of depression in patients with cancer vary depending on the type of screening and/or diagnostic tool used. In general, the prevalence of MDD is up to 38%, and the prevalence of any depressive disorder is up to 58%. The prevalence of depression is even greater in patients with advanced cancer. In the general population, the 12-month prevalence of MDD is 6%, and the lifetime prevalence is 16%. It’s useful to think about stress along a continuum of diagnoses ranging from a normal expected stress syndrome, an adjustment disorder, MDD triggered by the event, depression secondary to a general medical condition as can occur in central nervous system and pancreatic cancer, or even a substance-induced mood disorder from either prescribed medications or perhaps a form of coping that has turned maladaptive. Cognitive-behavioral therapy (CBT) can be explained as examining the way thoughts influence emotions and behavior. When using CBT with cancer patients, a good place to start is checking in on their understanding of their diagnosis, their prognosis, and current and future treatments. The goal is to see whether they have unnecessary cognitive distortions that may be affecting their emotions and behaviors. During periods of extreme stress, CBT can help patients by emphasizing the use of adaptive thoughts, and identifying maladaptive thoughts and behaviors as opportunities for intervention. To screen for depression, it may be enough to ask: “Are you depressed?” As a screening tool, the PHQ-2 asks only two questions: “Over the last 2 weeks, how often have you been bothered by the following problems: Little interest or pleasure in doing things, or been feeling down, depressed or hopeless? The PHQ-2 score ranges from 1 to 6, and even at the lowest score, it has a sensitivity and specificity of 90.6% and 65.4%, respectively, in detecting any depressive disorder. References Krebber AMH et al. Psycho-oncology. 2014 Feb;23(2)121-30. Walker J et al. Ann Oncol. 2013 Apr 1;24(4):895-900. Trinidad AC et al. Psychiatr Ann. 2011;4(9):439-42. Daniels S. J Adv Pract Oncol. 2015 Jan-Feb;6(1):54-6. Other resources PHQ-2: https://www.hiv.uw.edu/page/mental-health-screening/phq-2 National Cancer Institute: Depression–Health Professional Version: https://www.cancer.gov/about-cancer/coping/feelings/depression-hp-pdq