3 Questions on…

Answers straight from the experts on the latest news and topics in oncology

Tuesday, October 10, 2017

With Paolo Tralongo, MD; Mary S. McCabe, RN, MN; and Antonella Surbone, MD, PhD, FACP

By Sarah DiGiulio

The field of cancer survivorship care has grown significantly in the past 2 decades—yet there are still many very real challenges in the delivery of cancer survivorship care and meeting the needs of cancer survivors. That's the bottom line from three experts in the field: Paolo Tralongo, MD, Chief of the Medical Oncology Division at RAO Umberto I Hospital, Siracusa, Italy; Mary McCabe, RN, MN, Director of the Cancer Survivorship Initiative at Memorial Sloan Kettering Cancer Center, New York City; and Antonella Surbone, MD, PhD, FACP, Professor in the Division of Hematology and Medical Oncology at New York University School of Medicine, according to their recent editorial (J Clin Oncol 2017; https://doi.org/10.1200/JCO.2017.74.3450).

"Although significant success is certainly true for advocacy, it may be best to limit any celebration regarding the success of the medical management and care delivery aspects of survivorship care," the three noted. "Furthermore, the unique individual and sociocultural factors that play a major role in the delivery and acceptance of survivorship care are yet to be fully addressed."

They argue that better "categorization" of cancer survivors would help tailor care to better meet the very different needs for more patients on the spectrum of their post-cancer journeys.

1. What area of care for cancer survivors still needs attention and improvement?

Tralongo, McCabe & Surbone: "We wanted to make the point that survivorship care shouldn't have a one-size-fits-all approach. Rather, we now understand that care can and should be tailored based on treatment exposures. And, even though many survivors do very well, we should focus on assuring the highest quality of care for all individuals after treatment ends.

"Much progress has been made in terms of care and medical care in survivors. However, much still needs to be done to create the best survivorship care model. Many of these patients suffer from the late effects of active treatments—surgery, chemotherapy, radiotherapy—that are not only intended as physical disturbances, but also as psychological discomfort.

"Individual and sociocultural factors that play an important role in accepting survivorship care need to be taken into account. As the number of cancer survivors continues to increase, it becomes more and more important to educate health providers about the care standards that have been developed so to assure that survivors receive quality care internationally. Patient categorization is a further step forward."

2. How does patient categorization work when it comes to cancer survivorship care?

Surbone: "The categorization of cancer survivors that we have proposed in the present and past JCO articles requires a paradigm shift in the culture of cancer survivorship care, whereby we abandon a common, general approach to all cancer survivors in favor of the application of our epidemiologic knowledge and the developing risk assessment tools to tailor follow-up and recommendations to each individual cancer survivor. Cancer and survivorship care should both move to personalized precision approaches, as it is done in other chronic diseases.

"Personalizing follow-up will improve the medical and psychosocial care for each individual survivor and will help reduce the stigma of disease that still persists in many cultures."

Tralongo & McCabe: "The key thing to understand is that cancer survivorship is a formal period of care with a developing set of care guidelines that are specific to categories of patients, allowing for tailored, patient-centered care. Indeed, knowledge of these topics will help improve the care patterns, enabling better identification of individual disorders and individual risk."

3. What's the next step to developing better survivorship care models?

McCabe: "Research is still needed to evaluate the effectiveness of various models of survivorship care that have been developed, but not evaluated. Related research is needed to understand the most relevant models of care for underserved survivor populations. In addition, health services research is needed to evaluate the degree of dissemination of interventions developed for the management and prevention for long-term and late effects of treatment."

Tralongo: "At the same time, it is important to start rehabilitation pathways that should be considered as multidimensional/comprehensive rehabilitation, focused on improving or regaining both physical and psychosocial abilities, as needed from diagnosis onward."

Tralongo, McCabe & Surbone: "At the national level, ongoing efforts are needed by key organizations such as ASCO, American Cancer Society, National Comprehensive Cancer Network, and Institute of Medicine to continue their leadership in developing guidelines for clinical care of survivors.

"At the local level, a commitment is needed by the oncology community and primary care community to focus on the needs of survivors with attention to implementation of what we know along with researchers across the spectrum of medical, psychosocial, health services, and epidemiologic specialties, as well as to evaluate genetic mutations and environmental exposure."

Monday, September 25, 2017

With Skyler Johnson, MD, of Yale School of Medicine

By Sarah DiGiulio

Skyler Johnson, MD, a resident in the Department of Therapeutic Radiology, and his colleagues at Yale School of Medicine, New Haven, Conn., were bothered by a certain trend they noticed: their patients were refusing conventional cancer treatments at the time of diagnosis. They also were seeing that patients with advanced cancers who had been diagnosed much earlier had refused conventional treatment to try alternative medicines. After those therapies didn't work, they came back to receive conventional therapy.

Johnson's group used the National Cancer Database to look at patients diagnosed with the four most common cancers in the U.S. between 2004 and 2013 (breast, lung, prostate, and colorectal cancers). They compared outcomes for patients who chose an "unproven medical therapy delivered by a nonmedical professional" at the time of diagnosis with matched patients who chose conventional therapies. The data was stark.

Overall, the patients who chose alternative therapies had a 2.5-fold increased risk of death compared with patients who chose conventional therapy after 5 years. Looking only at patients with breast cancer, risk of death after 5 years was five times higher among the patients who chose alternative medicine. For patients with colorectal cancer, risk of death was four times higher for patients who chose alternative medicine. For patients with lung cancer, risk of death was two times higher among those who chose alternative medicines. And there was no statistically significant increased risk of death at 5 years for patients with prostate cancer who chose alternative medicine over conventional therapy, which Johnson noted was expected.

The data was published online ahead of print in the Journal of the National Cancer Institute (doi:10.1093/jnci/djx145). Here's what Johnson said cancer care providers and patients should know about these findings.

1. Were you surprised by the findings?

"I was surprised initially that [the increased risk of death with alternative medicines] weren't higher. Two-point-five sounds like a high number, but based on our anecdotal experience in clinic we thought it might be much worse.

"The data we collected was for initial treatment only, that first treatment decision that patients make [after they are diagnosed with a cancer]. Just like we were seeing patients whose cancers had advanced, gotten worse, and then they were coming [back] in for conventional therapies—that's perhaps what was happening in our dataset. So we likely under-ascertained for the true treatment affect. Some of these patients [who initially chose alternative therapies] may also have received a conventional cancer therapy later, which may have improved their survival.

"Plus the National Cancer Database only collects from accredited cancer centers. A lot of patients who were coming to see us after they had tried these alternative medicines were coming from different centers as well. So, there are a lot of patients treated at places where their data was not likely collected."

2. Is there clear data overall on how many patients choose alternative therapies over conventional treatment—and why?

"This is a really hard question to answer because we know there's a hesitancy on behalf of patients to tell their physicians this is the decision that they're going to make. So we really don't know how to quantify the exact number of patients doing it. Our dataset is small and it's only about 0.02 percent of the total patients in the dataset, but that likely underreports [the true number of patients who choose alternative medicines].

                "There was another code in the dataset where patients were refusing conventional cancer therapies and they didn't give a reason. We didn't include those patients because we didn't know what they were doing or why they were refusing, but it's likely that at least a majority or at least a portion of those patients were doing some form of alternative medicine, too. It's an area of further research that's needed.

"And it's hard to know why patients choose alternative over conventional therapies. There's marketing [from the alternative medicine industry]. It could be physicians not doing a good enough job explaining why to choose evidence-based treatment. It could be the patients themselves who feel that alternative medicines might be more effective or less toxic despite the lack of evidence for that claim."

3. What would you say is the bottom-line message about this work and alternative medicines for cancer treatment?

"Alternative medicines can be defined as unproven therapies. They may be being researched in preclinical settings or laboratory settings, but if they're unproven to work, they are not medicine. The discussion becomes more nuanced when talking about some complementary therapies. Someone who receives acupuncture or a botanical or other type of medicine as a complementary medicine may be able to safely do that—but they to do it under the guidance of their physicians in addition to their conventional therapies, not in lieu of conventional therapy.

"The long and short of it is that, if a person chooses alternative medicine for their curable cancer as their initial treatment choice, they are at greater risk of death than if they were to choose conventional cancer therapy. [How great that increased risk is] is dependent on which cancers they have. But there's a real risk associated with taking that decision that can affect their chance at cure and survival."

Thursday, September 7, 2017

With Adam Godzik, PhD, at Sanford Burnham Prebys Medical Discovery Institute

By Sarah DiGiulio​

Sophisticated new algorithms offer opportunities when it comes to understanding why cancers develop and finding treatments that work. The idea is to look at a patient's genome and look for genes where cancer mutations cluster in some specific regions of the gene (standard algorithms look for genes that have more mutations than would be expected according to the average mutation rate for that gene)—and that might be linked to a specific type of cancer or cancer drug known to work for other patients with that mutation.

But not every algorithm shows the complete picture. It's only when insights are combined from several algorithms that it becomes clear whether or not the right mutations are being correctly linked to the cancers they lead to or drugs that work for patients with those cancers, explained Adam Godzik, PhD, Director and Professor of the Bioinformatics and Structural Biology Program at Sanford Burnham Prebys Medical Discovery Institute in La Jolla, Calif.

Those were the findings of a paper Godzik and his colleagues recently published in Nature Methods (2017;14:782-788).

"The point here is that when results from various cancer genomic studies are presented, people usually see the final result of two actually independent things: data from the patients and the algorithm used to analyze these data," Godzik said. "When results from different studies are compared—with both data and algorithms being different—at the end we don't know what contributed to the difference."

This new research was designed to compare the effectiveness of multiple algorithms on the same set of data to reveal the difference each algorithm was finding.

"The key finding is that each algorithm in the group we compared is adding something unique, missed by other algorithms," Godzik noted. "The picture we get from using all of them is more complete than that obtained using just one algorithm."

In an interview with Oncology Times, Godzik elaborated about why these findings are significant, and what they reveal about the future of using algorithms for cancer diagnoses.

1. Why is this research important—especially as more and more algorithms for cancer are being developed?

"When you see two papers [that evaluate an algorithm for pinpointing a gene mutation that could lead to cancer], each of them have a different dataset and a different algorithm. So you may not actually be so sure what is causing the differences. Is it the difference in the data or is it the difference in how people analyze it, the algorithm?

"So in this case, these algorithms that we looked at—each of them is giving us part of the truth. And the best insights we get is that, when we combine all these algorithms together, we see the global picture."

2. So you're not saying your data shows any one algorithm is necessarily wrong? What's the takeaway about each specific algorithm you looked at?

"Each of the observations might be true. If you have a group of people who are looking at people with breast cancer, somebody analyzes that and says there's a group that has mutations in [a specific] gene and this group has low survivability and should get more aggressive treatment. We're saying, well if you use another algorithm you might see another group [that has that gene but needs another type of treatment].

"It's not like one algorithm is correct and another algorithm is wrong. Each algorithm is showing you part of the truth and you would be missing something if you don't use multiple algorithms. Most observations they would make would be correct, but it wouldn't be all of the truth. Some algorithms would miss some of those subgroups. And we still don't know, in most cases, what it means. But in the future, we anticipate we'll know how the different subgroups could be treated differently.

"For instance, a big drug trial may fail because they take 1,000 people and give the drug to these people and it only helps 20 people. So, they say it's not good enough and the drug is not approved. But with tools like [these algorithms] we can say yes, it only helped 20 people, but it helped 100 percent of people who have a certain feature or a certain set of mutations. And this could be very useful because now we can say, well, the drug is not for everybody, but the drug can work for this one specific group.

"So this is the big picture here. This is the dream."

3. What is most important for oncology clinicians to know about your findings—and the future of using algorithms to diagnose and classify cancers?

"Doctors: Pay attention to how the data was analyzed, it could be as important as what is being analyzed.

"I think it would be too early to say these tools are usable now—or give a lot of insights for practicing clinicians. At this point in day-to-day clinical practice, genomic information is very rarely used or may only focus on one or two specific genes, like BRCA1/2. But this research is part of a bigger trend of more and more detailed analyses coming from cancer genomes."

Friday, August 25, 2017

With Betty Ferrell, RN, PHD, in the Department of Population Sciences at City of Hope

By Sarah DiGiulio

It was as recently as 2012 that ASCO issued its first guidance on integrating palliative care as a standard part of oncology care. And in a clinical practice guideline update released earlier this year, ASCO revised its recommendations based on new evidence (J Clin Oncol 2017;35:96-112).

"A key emphasis is the need to integrate palliative care much earlier in the course of illness and treatment," explained the update's lead author Betty Ferrell, RN, PhD, Director and Professor in the Division of Nursing Research and Education in the Department of Population Sciences at City of Hope, Duarte, Calif. "These guidelines reflect a growing body of solid evidence for the benefits of palliative care to improve patient quality of life. "This version also emphasizes that [palliative care] should be provided by the oncology team as well as the [palliative care] specialty service," Ferrell said.

Key recommendations from the expert panel who wrote the guidelines (based on a systematic review of literature) that were included in the updated guidelines include the following:

  • All patients with advanced cancer—whether patient or outpatient—should receive palliative care services early in the course of their treatment, concurrent with active treatment.
  • For newly-diagnosed patients with advanced cancer, referral to palliative care services should happen with 8 weeks of diagnosis.
  • Essential components of palliative care services may include symptom, distress, and functional status management (such as pain, dyspnea, fatigue, sleep disturbance, mood, nausea, or constipation); clarification of treatment goals; exploration of understanding and education about illness and prognosis; assessment and support of coping needs; coordination with other care providers; and referral to other care providers, if needed.

The new guideline makes it clear that these palliative care services can be provided by an interdisciplinary palliative care team or by the patients' nurses, social workers, or other providers. What's important is that all patients with advanced cancers have access to these services.

Ferrell elaborated on why the revisions are important and the barriers still standing in the way of more comprehensive palliative care services for patients with cancer.

1. Why were these palliative care guidelines updated most recently?

"The health care system is so burdened with limited resources, and we need new models of care. In previous years, [palliative care] was seen as only indicated at the end of life. However, there is growing awareness that all patients experience symptoms and [quality of life] concerns that would benefit greatly from [palliative care].

"There is also an important issue of the aging of our population. Our cancer patients are older and they come with many comorbidities [that are] also compromising their quality of life. And finally, improved cancer treatment means that patients live much longer, even those with advanced disease. We need to support our patients who now are living years with significant quality of life concerns."

2. The oncology community has been talking about the importance of palliative care for several years—are we there yet, and what are barriers that still impede efforts to make these services more widely available?

"We have made significant progress. There is broad acceptance across most oncology settings that palliative care is essential to quality oncology care.

"Barriers remain, however. Patients and families are often reluctant to accept palliative care as they associate it with end-of-life care. Unfortunately, patients are often not referred for palliative care until very late, and referrals to hospice come even later. There is a major need to increase palliative care knowledge and skill in the entire oncology workforce as all clinicians practicing in the field of oncology need [a] generalist level of competence in palliative care.

"The key paradigm shift [over the past 5 years, since the first guidelines were developed,] is that palliative care is now firmly established as a specialty in medicine, nursing, and other disciplines. There is also a very substantial body of evidence supporting the benefits of palliative care to health systems and to patients."

3. What is the bottom line about these updated guidelines and providing palliative care services to patients with cancer?

"Palliative care improves quality of life for patients, supports family caregivers, extends survival, and benefits health care systems.

"Palliative care is important for all cancer patients across the care trajectory."

Thursday, August 10, 2017

With Carol Parise, PhD, Research Scientist at Sutter Institute for Medical Research

By Sarah DiGiulio

On the list of factors that affect a patient's outcome after being diagnosed with cancer is marital status. Research that looked at more than 730,000 patients with any one of the 10 leading cancers in the U.S. suggests that being married yields an advantage for patients with cancer in terms of having a lower risk of having metastatic disease, under-treatment, and death from cancer (J Clin Oncol 2013;31:3869-3876). But now new research suggests the story might be different for some people, depending on their race.

The new data included 23,493 women who had been diagnosed with triple negative breast cancer. The findings were presented during a poster presentation at the 2017 ASCO Annual Meeting (Abstract 1098).

"Being married at the time of diagnosis of triple negative breast cancer provides a survival advantage for women who are white and Asian/Pacific Islander, but not for black or Hispanic women," study author Carol Parise, PhD, Research Scientist at Sutter Institute for Medical Research, Sacramento, Calif., shared with Oncology Times.

The data also showed that the single white and Asian/Pacific Islander women with triple negative breast cancer had worse survival than women who were white and Asian/Pacific Islander and married at the time they were diagnosed with the disease.

Of the women in the study, 13,241 were white, 2,775 were black, 5,059 were Hispanic, and 2,418 were Asian/Pacific Islander. The researchers used Kaplan-Meier survival analysis and Cox regression to assess the risk of mortality associated with marital status (married, single/never married, separated, divorced, or widowed). The models were adjusted for cancer stage and grade, age, socioeconomic status, and treatment type.

Here's why Parise says these findings are significant and what implications they have for addressing disparities in cancer care outcomes.

1. What led you to specifically look at how marital status affects breast cancer outcomes among different races?

"Our research in breast cancer has centered on the topic of disparities in incidence and mortality due to race/ethnicity and socioeconomic status. Since marital status has been shown to be an advantage for cancer survival, we wanted to know if this was true for all race/ethnicities for the subtype of breast cancer with the worst survival.

"We investigated whether there was a survival advantage [in triple negative breast cancer] for women of the same race/ethnicity who were married versus single, divorced, and widowed. No other study has compared differences in risk of mortality of [triple negative breast cancer] associated with being married within a single race."

2. Why do you suspect that race played a role in whether or not being married provided a survival advantage for the women in this study with triple negative breast cancer—and do you suspect the same pattern would exist for patients with other types of cancer, too?

"We cannot draw conclusions given the nature of our data, but we can speculate that since social support is a correlate of survival for breast cancer that this could account for why marital status is associated with improved survival. This area deserves further research.

"We focused on [triple negative breast cancer] because it is the subtype with the worst survival. ... While we did not conduct the analysis with the combined subtypes for each race, we believe the results would be similar for all cancers."

3. What is the next step given these findings?

"This study was an epidemiologic investigation. These types of studies tend to raise more questions than answers since they are correlational in nature.

"While we do not have the resources to further pursue this topic, a next step would be to determine the social support factors that are important for women with [triple negative breast cancer] and determine if there are differences in what constitutes support for women of different races. It appears as if there are other factors associated with survival besides surgery, radiation, [chemotherapy], and hormonal therapy—and these should be explored."