ASCO Education

In part one of this two-part ASCO Education Podcast episode, Dr. Sonali Smith (University of Chicago Medicine) and Dr. Paolo Strati (MD Anderson Cancer Center) discuss the application of recently approved therapies for diffuse large B-cell lymphoma through examination of challenging patient cases. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: education.asco.org | Contact Us Air Date: 10/20/21 TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] SONALI SMITH: Hello, and welcome to this episode of the ASCO Education Podcast highlighting new therapies for lymphoma. My name is Dr. Sonali Smith, and I'm a hematologist and medical oncologist specializing in lymphoma and clinical investigation in lymphoma. I'm also the Elwood V. Jensen Professor and chief of the hematology/oncology section at the University of Chicago, and very excited to be joined by my colleague, Dr. Paolo Strati. PAOLO STRATI: Good morning to everybody. My name is Paolo Strati. I'm a hematologist and medical oncologist and an assistant professor in the Department of Lymphoma/Myeloma, and in the Department of Translational Molecular Pathology at MD Anderson Cancer Center, Houston, Texas. And I'm also the clinical director for the Lymphma Tissue Bank. In part one of this podcast episode, we will discuss the adoption of recently approved therapies for diffuse large B-cell lymphoma, such as selinexor, tafasitamab, Liso-Cel, and Lonca-T. These therapies have transformed care for patients with this disease. And we'll start our conversation today with a patient case. SONALI SMITH: Great. Well, I'll go ahead and present a patient to you, Paulo. So this is a 78-year-old man with diffuse large B-cell lymphoma that is the germinal center-derived subtype. It is not double expressor, it is not double-hit. He has advanced stage disease with a high IPI, as well as the high CNS IPI. Luckily, his performance status is zero and he has no significant comorbidities or other health conditions. He received frontline dose-adjusted EPOC-R with intrathecal methotrexate for six cycles. But at the end, he had a partial remission. So how do you select your salvage therapy in this situation? Are you concerned about using agents targeting CD19 in the second line, given the potential need to use anti-CD19 cellular therapy, or CAR-T in the third line? PAOLO STRATI: This is a very interesting and unfortunately not uncommon case. And thank you, Sonali, for asking these very important questions. Technically, a platinum-based regimen followed by autologous transplant will be a standard answer and may be feasible. Because as you mentioned, this patient has a good performance status and non-meaningful comorbid health conditions. However, patients who are refractory to a frontline anthracycline-based regimen, such as in this case, with achievement only of partial remission at the end of frontline dose-adjusted EPOC, can potentially experience a suboptimal outcome following the standard approach with a platinum-based second line regimen. And as such, alternative strategies may be needed. To this regard, the combination of tafasitamab that, as you know, is a monoclonal antibody targeting CD19, and lenalidomide, an oral immunomodulatory agent, a combination which is currently approved by the FDA in the United States as a standard second line option for transplant ineligible patients, would be a great option in this case. Data from the three year follow-up of the phase II study that has brought to the FDA approval this combination, the L-MIND had been recently presented and have showed the complete remission rate of 40% and immediate duration of response of 44 months, including patients who received this regimen as a third line or beyond. So there is, of course, a biological concern by targeting CD19 in second line. These may potentially impact a third line use of an autologous anti-CD19 CAR-T, because CD19 downregulation may potentially be a mechanism of escape to tafasitamab. And recent data has shown the CD19 levels are strongly associated with the efficacy of CAR-T cell therapy in patients with large B-cell lymphoma. Small retrospective studies have shown that autologous anti-CD19 CAR-T can be safely and effectively used after antibodies or antibody drug conjugate targeting CD19. But we need a significantly larger and prospective data, including serial tissue biopsy in these patients before considering this combination as a standard practice in patients for whom we plan to use CAR-T as a third line. Until then, I would be cautious in using second line tafasitamab in patients, again, for whom there is a potential plan for anti-CD19 autologous CAR-T in third line. And if necessary, limited to very selective cases. Finally, recent press releases have anticipated the two autologous anti-CD19 CAR-T products, Axi-Cel and Liso-Cel, are superior to autologous settings transplanted in second line. And so in the near future, CAR-T cell therapy may become a standard second line option. And that would be an ideal option in primary chemorefractory patients as the case that you presented here. SONALI SMITH: Yeah, I agree. There are a tremendous number of options. And having anti-CD19 products as well as autologous stem cell transplant, the sequencing will be an evolution. So going back to this patient, he received tafasitamab and lenalidomide for two cycles with no significant toxicity, but unfortunately, he had further progression after two cycles based on a PET/CT scan. So what are your next steps? Would you move directly to an autologous anti-CD19 CAR-T cell therapy now? Would you re-biopsy before that? And how would you select among the three available CAR-T products? PAOLO STRATI: These are not easy questions, particularly the selection of one out of three available CAR-T products. As you said, there are currently three autologous anti-CD19 CAR-T products approved by the FDA in the United States for the treatment of large B-cell lymphoma in third line or beyond. And these are Axi-Cel, Tisa-Cel, and Liso-Cel. For all of them, the best outcome is observed for patients who have a low turmor burden at time of CAR-T infusion. And they need to either select patients with no bulky disease or to decrease it through bridging therapy. And as we define bridging therapy given between leukapharesis and CAR-T infusion. Unfortunately, there is currently no standard bridging therapy and all FDA products approved in third line can potentially be used in this specific scenario that you described, including polatuzumab with bendamustine/rituximab, selinexor, and Lonca-T, of course, beyond tafasitamab and len that has already been used in this case. Of course, when selecting a bridging therapy, there are many disease-related and patient-related factors to take into consideration, including the need to preserve the host immune microenvironment that we all know is crucial for the subsequent activity of CAR-T cells. And also, we need to give into consideration the need to preserve as much as possible, as we discussed previously, in CD19 expression. To this regard, and going back to one of your questions, I strongly recommend to re-biopsy patients if any bridging therapy is used between bridging therapy and CAR-T infusion in order to document CD19 expression before CAR-T infusion. When it comes to CAR-T product selection, as I said, it's a really difficult decision to do. And we don't have at this time randomized trials in third line. And as such, the decision is really left to the treating physician based on multiple factors. But all of the limitations of inter-study comparison, efficacy seems to be pretty much the same for the two products, maybe slightly higher based on the recent second line data. But Axi-Cel and Liso-Cel as compared to Tisa-Cel, and also as suggested by recent press release. However, due to the fact that Liso-Cel and Tisa-Cel have less potent co-stimulatory domain for 1BB instead of CD28, the rate of CRS and ICANS, the two main toxicities associated with CAR-T cell therapy, is usually lower with this to the point that some centers are able to infuse them in the outpatient setting, whereas Axi-Cel is almost always infused in the inpatient setting so the toxicity can be monitored more closely. So with older patients or those who have comorbid health condition, Tisa-Cel and Liso-Cel may be a safer option, though there's a lot of research going on trying to mitigate toxicities associated with Axi-Cel. Finally, it's important to keep in mind manufacturing time. Axi-Cel is manufactured in an average of 17 days, whereas Tisa-Cel and Liso-Cel take typically longer than three to four weeks. This can be itself a determining factor, particularly for patients who are quickly progressing and where immediate treatment is needed. SONALI SMITH: Yeah, I agree. I think there are going to be many patient product and disease-based factors that will impact both the effectiveness as well as the toxicity. And you did a really great job of explaining the role of the co-stimulatory domain potentially in some of that, as well as all of the products that are out there. It's definitely a complicated area. Going back to our patient, so he did undergo leukapharesis for Liso-Cel and received third line polatuzumab and rituximab without bendamustine. The restaging PET/CT after two cycles showed a PR with a significant decrease in tumor burden, and repeated biopsy showed high expression of CD19 by flow cytometry. He then proceeded with Liso-Cel, which was relatively well tolerated. There was only grade 1 cytokine release syndrome and no ICANS, so no neurotoxicity. And his day 30 PET/CT showed a complete remission. Unfortunately, the 90 day PET/CT showed progression. So Dr. Strati what is the outcome for patients who relapse after CAR-T? Do you recommend to re-biopsy? And what are the efficacy data for FDA approved agents for these patients? And I know this is a long question, but is there any role for repeated CAR-T or allogeneic transplant now? PAOLO STRATI: Unfortunately, currently, the outcome of patients with large B-cell lymphoma relapse or progress after autologous anti-CD19 CAR-T is suboptimal, with a life expectancy, unfortunately, shorter than six months. Hence, the need to be creative and customize treatment based on biological data. To this regard, I think it's crucial to repeat a tissue biopsy to guide subsequent therapy. As mentioned previously, there are currently four products approved by the FDA for patients with large B-cell lymphoma in third line and beyond. Two of these target CD19, tafasitamab plus lenalidomide and Lonca-T One targets CD79B, polatuzumab combined with bendamustine and rituximab. And one is an SPO1 inhibitor, selinexor. While we have no data for selinexor in patients who relapse or progress after CAR-T cell therapy, limited prospective data showed that a progression-free survival in the order of weeks is usually observed for patients who receive polatuzumab with or without bendamustine and rituximab after CAR-T cell therapy. So I would not recommend that. However, there's some interesting activity in the post-CAR-T setting for Lonca-T and for tafasitamab/len is limited to patients who still express CD19 in time of relapse. And of course, it needs to be largely and prospectively further investigated before becoming a standard approach for patients who relapse or progress after CAR-T cell therapy. When it comes to cellular therapy, repeated anti-CD19 CAR-T infusion is not shown to be successful in the original registration studies. So it is not currently something that I would recommend and is not definitely a common practice. And very limited retrospective studies have shown the use of allogeneic stem cell transplants in the post-CAR-T setting may be associated with quite elevated treatment-related mortality. So I don't suggest this as a standard practice in large B-cell lymphoma at this time. This is different from B acute lymphoblastic leukemia, where instead, allogeneic stem cell transplant is becoming progressively a standard approach. And we definitely need more data before using this consistently. While we strive to identify the optimal cell batch therapy for large B-cell lymphoma patients who relapse or progress after CAR-T cell therapy. I think the priority should be given to clinical trials, including CAR-T targeting molecules other than CD19, such as CD20, CD22, CD79B, allogeneic CAR-T there are immediately available, so without the need to wait for manufacturing times. And K-CAR, that may be less toxic than CAR-T and other non-cellular therapy biological agents. So definitely, clinical trials are, at this time, the best approach in patients who relapse after CAR-T cell therapy, as the case that you described. SONALI SMITH: Thank you Dr. Strati. As an update, this patient had repeated biopsy showing a CD19 positive relapse. He consented for a clinical trial with a novel NK-CAR targeting CD19, achieving CR which is still ongoing at nine months. And this case really does represent some of the most exciting advances that we've had for this disease for patients who can tolerate aggressive therapies and have access to clinical trials. PAOLO STRATI: Dr. Smith, I'd like to hear your opinion about another patient with diffuse large B-cell lymphoma. This patient is an 81-year-old man with a history of coronary artery disease and well-controlled diabetes mellitus, who noticed a right cervical lymph node while shaving that seemed to have popped up. He was evaluated by his primary care physician and given a course of antimicrobials. 10 days later, the lymphoma seems to be enlarging and he is referred to ENT pharyngeal biopsy. The specimen is small but shows follicular lymphoma in a portion of the sample. However, there is also concern for larger cells and possible transformation. The patient is also beginning to note night sweats and a decreased appetite. And labs are notable for elevated LDH, 500, and thrombocytopenia with a platelet count of 110. So Dr. Smith, in your opinion, is this specimen sufficient to start treatment? Or should treatment be delayed to get a larger and maybe excisional biopsy? SONALI SMITH: Yeah, thank you for this question. I think this is a challenge we have in the clinic all the time, which is what is a sufficient biopsy specimen to make a diagnosis that allows us to subtype lymphoma? As we know, every lymphoma subtype, the treatment is really guided by the histology and not so much the stage or some other factors. So having a needle biopsy is unfortunately often insufficient. In this case, we have a very strong concern for a possible transformation. And as we know, both follicular lymphoma and diffuse large B-cell lymphoma can mark very similarly when it comes to immunophenotype. Certainly, the germinal center type of diffuse large B-cell lymphoma or any transformed follicular lymphoma will be CD20 positive, CD10 positive, and it really requires architecture to be able to tell whether or not there are sheets of large cells. So the ideal outcome for this patient would be to have a biopsy that is done promptly that allows us not only to confirm whether or not there is histologic evidence of transformation, but also to conduct FISH studies to determine if there's acquisition of a MYC rearrangement. At its core, all follicular lymphoma patients essentially have a transformation of 14;18, leading to BCL2 rearrangement and BCL2 overexpression. During the transformation process, there can be an acquisition of a MYC rearrangement, which would then make this a double-hit lymphoma and certainly has a much worse prognosis and may also prompt a change in treatment if the patient can tolerate more intensive therapy. So my recommendation would be to have a biopsy. Now one other aspect is that sometimes, we don't really have the time to proceed with a biopsy, or the lymph node may be in an inaccessible area. And in that case, there are some other criteria that we can use to assume that somebody has a transformation. Symptoms such as profound B symptoms and elevated LDH, and sometimes, a PET scan with multiple areas of very high avidity, can lead you to feel or suggest that this person has a transformation. There is some controversy over the use of PET and we know it does not confirm a diagnosis of transformation. But in my opinion, this is very suggestive if there are many areas of high SUV. PAOLO STRATI: Thank you, Dr. Smith. I agree completely about the importance, when time allows, to perform either a larger core biopsy or an excisional biopsy, because as you very well-outlined, this has not just a mere diagnostic purpose, but can meaningfully affect treatment planning for patients. And actually, in this case, as you suggested, the patient eventually had multiple core biopsy that showed transformed follicular lymphoma with very evident areas of diffuse large B-cell lymphoma. FISH, as expected for follicular lymphoma, was positive for translocation for TN18, but luckily negative for MYC rearrangement. So fortunately, we didn't have to deal with a double-hit lymphoma. The remainder of his staging showed he had diffuse lymphadenopathy. And PET scan, as you mentioned, has a controversial role in the diagnosis of transformation. So there's some areas that had high avidity with an uptake with an SUV of 1215, whereas other areas were less intense with SUV 618. And usually, heterogeneity in SUV actually helps further supporting diagnosis or transformation. While meta-maps showed follicular lymphoma, no large cells. So movement was isolated in the B-cell lymphoma. So Dr. Smith, at this point, based on the provided information, what's your treatment approach in this older patient and also a patient with comorbid health conditions, but with diffuse large B-cell lymphoma? SONALI SMITH: Yes. The goal of treating any aggressive lymphoma is to obtain remission, and if the remission lasts, to hopefully offer cure to the patient. And when somebody has a transformed lymphoma, of course, there is a dual concern, which is that the aggressive component can potentially be put into remission in a durable way achieving cure. But the indolent component will always need to be monitored, although hopefully, will not be life threatening the way the aggressive component can be. Treating an octogenarian is really challenging, particularly due to comorbidities in this age group and the potential toxicity of chemotherapy. So the standard of care for diffuse large B-cell lymphoma is anthracycline-based chemotherapy. But this, of course, can have significant toxicity in older patients. And in addition, the vincristine can aggravate neuropathy. And I've personally found that the high dose steroids that are part of CHOP can also cause toxicity in older patients and patients who are frail. So unfortunately, the literature is somewhat sparse. But we do have several data sets that can guide management in this particular patient situation. The French published, over a decade ago, the development of R mini CHOP, that includes an attenuated dose of cyclophosphamide, doxorubicin, and vincristine, and leads to some durable remissions and cure. Unfortunately, the long-term overall survival is less than 50% with R mini CHOP. And so although this is an appropriate backbone, there's certainly a lot of room for improvement. And there's also toxicity even with R mini CHOP. So in their initial phase II trial, there was actual deaths related to the R mini CHOP, particularly in the first cycle or two, really necessitating some type of pre-phase help ease patients into the chemotherapy. One of the challenges that we face in the clinic is that when we meet an older patient, we both want to maximize our chance for cure, but also minimize the toxicity that is particularly pronounced. And there is very little data in terms of how to guide this at the bedside. I'm excited that SWOG, with the US Intergroup, is conducting a trial, S1918, which prospectively includes a frailty assessment tool that was developed by the Italian group in lymphoma, and then also includes serial comprehensive geriatric assessment so that we can get a better idea about quality of life both during and after treatment. So there is no great standard of care right now, but I would say that R mini CHOP, outside of a trial, is a very reasonable way to proceed. PAOLO STRATI: Dr. Smith, thank you for outlining so well what we can do to minimize toxicity and to better select patients for this type of treatment. And as an Italian practitioner in the United States, I am very excited that the Italian frailty tool will be used in this SWOG trial. Are there any other ways to further improve safety when we use chemo immunotherapy in older patients or patients with comorbid health conditions? In particular, there is a lot of concern about potentially infectious complications in these patients. And so I'm wondering if there's any routine antimicrobial prophylaxis that you recommend. SONALI SMITH: Yes. I think it's really important to maximize supportive care for our older patients with aggressive lymphomas getting intensive therapy. I did mention the pre-phase, and I would just like to mention that one more time because I do think there's data that providing a brief pre-phase can minimize toxicity with the first cycle. And how this pre-phase is given is highly variable. Again, the data is somewhat limited, but it typically includes steroids given for five to seven days with or without a dose of vincristine. And steroids themselves can have toxicity. And the dose of the steroids, I think, is somewhat controversial. In my personal practice, I use somewhere between 40 to 60 milligrams per day for five to seven days. And I do not typically use vincristine, although a prospective French trial recently did and showed that this significantly improved toxicity. Other complications that can occur really are related to infection. And so, of course, all patients should have growth factor support as per ASCO guidelines. But I also routinely give VZV prophylaxis with acyclovir or valacyclovir. And for the first cycle in particular, I have patients come back to clinic after the first dose one week later to ensure that the counts are stable and that they are doing well. This is really where our team of nurses and other providers who are part of the care team are so important and communication is also very important. PAOLO STRATI: So Dr. Smith, as you suggested, also, this patient actually received mini R-CHOP without any complications. And end-of-treatment PET/CT can showed a VL score of 3, so a complete metabolic remission, potentially. How do you interpret these findings? SONALI SMITH: So response criteria in clinical trials, and then of course, extrapolated to the clinic, have evolved in lymphoma. And the Deauville or the International Prognostic Scoring System that has been used typically defines a uptake relative to liver and mediastinal blood pool. And those patients who have a Deauville 1 to 2, which is less than that bar, is considered negative. And 4 to 5 is positive, with five being the emergence of new sites of adenopathy. The interpretation of a Deauville 3 can be somewhat more complicated, but this really outlines the limitations of just using the SUV or the PET scan uptake to measure response. For my patient and for this patient, the lymph nodes all substantially decreased in size. And having some type of combined interpretation of the uptake, as well as the size that has decreased, I think is going to be a very important part of how we approach patients going forward. So for this patient, I opted for close observation after the completion of therapy and felt that his Deauville 3, along with the decrease in the size of the lymph nodes, was very significant. PAOLO STRATI: I completely agree with that. Where PET scan is an extremely helpful tool, particularly for the management of aggressive B-cell lymphoma, can also become a major challenge when it comes to its interpretation for these borderline scenarios. And as you said, it's very important to add into the equation multiple parameters, including CT findings and overall patient performance status symptoms. So that's all we have for today. Thank you, Dr. Smith. This was a great conversation. We have learned and discussed a lot about diffuse large B-cell lymphoma, including novel biological agents, CAR-T cell therapy, management of elderly patients, and patients with comorbid health conditions and interpretation of PET/CT scan. I think this will be very helpful. And the conversation will continue beyond this podcast. In part 2 of this episode, airing in November, we will discuss new therapies for mantle cell lymphoma and for follicular lymphoma. Thank you so much to all the listeners tuning into this episode of the ASCO Educational Podcast. SONALI SMITH: Thank you. It's been a pleasure to speak with you today. [MUSIC PLAYING] SPEAKER: Thank you for listening to this week's episode of the ASCO e-learning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

In the second edition of this two-part Oncology, Etc. episode, hosts Dr. Patrick Loehrer (Indiana University) and Dr. David Johnson (University of Texas) continue their conversation with Dr. Otis Brawley, a distinguished professor of Oncology at Johns Hopkins and former Executive Vice President of the American Cancer Society. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 10/5/2021 TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] DAVID JOHNSON: Welcome back to Oncology, Etc, and our second segment of our conversation with Otis Brawley, professor of Medicine at Johns Hopkins Medical School and the Bloomberg School of Public Health. Pat, I don't know about you, but Otis is a very impressive man, and he had a lot of really interesting things to say about his career development, family, et cetera in the first segment. This second segment, we're going to get to hear more about his time at the ACS. What were your thoughts about segment one? PATRICK LOEHRER: Well, I loved talking to Otis, and you too, Dave. Parenthetically, Otis once told me in a dinner conversation we had that he felt like Forrest Gump, and I can identify with that. Where over the field, our field of oncology over the last several decades, we've met some incredibly wonderful people, and we've been lucky to be part of the history. The three of us, I think, do have a deep sense of the historical context of oncology. This is a young field, and there's just some extraordinary people, many of them real true heroes, and Otis has his figure on the pulse of that. DAVID JOHNSON: Yeah, that's why he's been in some of the right places at the right time, and we'll hear more about that in this segment coming up now. PATRICK LOEHRER: Now Otis has had a career in many different areas, including ODAC, the NCI, the ACS, now at Hopkins. So let's hear a little bit more about Dr. Brawley's experience at the American Cancer Society and particularly with his experience with the former CEO, John Seffrin. DAVID JOHNSON: Sounds great. [MUSIC PLAYING] OTIS BRAWLEY: John and I had a wonderful run at the American Cancer Society. Got to do a lot of things. Got to testify for the Affordable Care Act. Got to do some of the science to actually argue that the Affordable Care Act would help. And I was fortunate enough to be there long enough to do some of the science to show that the Affordable Care Act is helping. DAVID JOHNSON: Yeah, I mean actually all of the things you accomplished at the ACS are truly amazing. Let me ask you, just on a personal level, what did you like most about that job, and then what did you like least about that job? [LAUGHTER] OTIS BRAWLEY: I like the fact-- there were a lot of things I liked about that job. There were a couple hundred scientists and scientific support people that you got to work with. And I used to always say, I do politics so you can do science. And what I used to like the most, every Wednesday afternoon that I was in town, I would walk around just to watch those people think. I used to joke around and say, I'm just walking around to see who came to work today. But I really enjoyed watching them work and watching them think, and that was fun. Another fun aspect of the job was people used to call and ask a little bit about the disease that they are a family member would have. And sitting down with them on the phone in those days-- we didn't have Zoom-- and talking to them through their disease. Not necessarily giving them advice on what to do in terms of treatment, but helping them understand the biology of the disease or connecting them with someone who was good in their disease. And I happen to, by the way, have sent some patients to both of you guys. That was a lot of fun. Then the other thing, of course, was the fact that you could actually influence policy and fix things. I'll never forget sitting across from Terry Branstad, then the governor of Iowa, and convincing him that the right thing to do is to raise the excise tax on tobacco in Iowa. Being able to see that you're effective and to see that you're positively influencing things. The bad side, some of the politics. I didn't necessarily like how some of the money was being raised or where they were raising money from. I think that you have to have a certain standard in terms of where you accept money. And we always had that tension with the fundraisers. But it's also true-- and I will give them a nod-- you can't do the fun things unless you raise money. So I really truly enjoyed my time at the American Cancer Society. And by the way, a shout out to Karen Knudsen, who is the CEO running the American Cancer Society now. And I'm fully committed to helping the ACS and helping Karen be successful. DAVID JOHNSON: One of the things I read-- I think I read this that you had said that one of your proudest accomplishments was revising the ACS screening guidelines. Tell us just a little bit about that. OTIS BRAWLEY: Yeah, going all the way back to the early 1990s, I started realizing that a lot of these guidelines for screening, or back then, this is before the NCCN guidelines for treatment even, that were published by various organizations, including the American Cancer Society. We're almost the equivalent of-- get the impression that in the 1960s, it would have been a smoke-filled room. But you gather a bunch of people into a room, and they come up with, this is what we should be doing. Indeed, the American Cancer Society in 1991 endorsed annual PSA screening for prostate cancer based purely on getting a group of primarily urologists into a room, and that's what they came up with. There was very little review of the science. There really was no science at that time except the science to show that PSA screening found cancer. There were no studies to show that led to men benefiting in that they didn't die. Indeed, in 1991, there was no study to show that treatment of early prostate cancer saved lives. The study to show treatment of prostate cancer saves lives was first published in 2003, and the radiation saves lives in 1997, 1998. Surgery saves lives in 2003 and screening has a small effect published in 2009. But they started recommending it in 1991 in this almost smoke-filled room kind of atmosphere. When I got to the American Cancer Society, I started an effort, and we involved people from the National Academy of Medicine, we involved people from the NCCN, from the American Urological Association, the American Academy of Family Physicians, the American College of Physicians. And we got together in that almost smoke-filled room again, but the idea was, how do you make responsible guidelines? And we wrote that up into a paper guide widely accepted by all of the organizations, and it involves a review of the literature that is commissioned by someone. And they spend a long time reviewing the literature and writing a literature review. And then you have a group of experts from various fields to include epidemiology and screening, social work, someone who's had the disease. Not just the surgeons and medical oncologists who treat the disease but some population scientists as well. They sit down and they reveal all of the scientific data, and then they start coming up with, we recommend this. And then they rank how strong that recommendation is based on the data. We published this in 2013 in The Journal of the American Medical Association. I do think that was important, you're right. That's Otis trying to bring his policy and his belief in orthodox approach to science and bring it all together. PATRICK LOEHRER: So let me reflect a little bit more on something. There is a book that I also just recently read by Dax-Devlon Ross, and it's a book entitled, Letters to my White Male Friends, and it was a fascinating read to me. You have this public persona and professional persona of being an outstanding physician, clinician, public speaker. But what we the three of us have never really had the conversation today is we have much more interest now in DEI. One of our other speakers talked about the fact that there's a tax that is placed upon underrepresented minorities and academics. They are all expected to be on committees. They have to be doing different things. And so the things that they love to do, they can't do it because they have to represent their race or their gender or their ethnicity. OTIS BRAWLEY: I have been blessed and fortunate. There are problems, and there are huge burdens that Black doctors, and women doctors by the way, have to carry. I have been fortunate that I have skated through without a lot of that burden. Maybe it has to do with oncology, but I will tell you that I have been helped by so many doctors, men and women, predominantly white, but some Asian, Muslim, Jewish, Christian. I don't know if it's oncology is selective of people who want to give folks a fair shake and really believe in mentoring and finding a protege and promoting their career. I have been incredibly, incredibly fortunate. Now that I say that, there are doctors, minority doctors and women, who don't have the benefits and don't have the fortunes that I have had, and we all have to be careful for that. As I said early on, John Altman told me that I will thank him by getting more Blacks and women into the old boys club. And so that was his realizing that there is a-- or there was a problem. I think there still is a problem in terms of diversity. Now I have seen personally some of the problem more outside of oncology in some of the other specialties. More in internal medicine and surgery, for example. By the way, there are also some benefit. I did well in medical school in third and fourth year in medical school at the University of Chicago because there were a group of Black nurses who were held that I wasn't going to fail. The nurses took me under their wing and taught me how to draw blood, how to pass a swan. The first code I ever called, there was a nurse standing behind me with the check off list. And so there are some advantages to being Black as well. But there are some disadvantages. I've been very fortunate. My advice to Black physicians is to keep an open mind and seek out the folks in medicine who truly do want to help you and truly do want to mentor you. And for the folks who are not minority or not women in medicine, I say, try to keep an open mind and try to help everybody equally. PATRICK LOEHRER: Thank you. DAVID JOHNSON: I want to go back to your book for a moment. And again, for those who've not read it, I would encourage them to do. So it's a really honest book, I think, well-written. You made a comment in there-- I want to make sure I quote it near correctly. You said that improvement in our health care system must be a bottom up process. What do you mean by "bottom up?" OTIS BRAWLEY: Well, much of it is driven by demand from patients and other folks. The name of the book was, How We Do Harm. And the synopsis is there are bunch of people who are harmed because they don't get the care that they need. And there's a bunch of people who are harmed because they get too much medicine and too much care. And they rob those resources away from the folks who don't get care at the same time that they're harmed by being overtreated, getting treatments that they don't need. The other thing, if I can add, in American health care, we don't stress risk reduction enough. I used to call it "prevention." Some of the survivors convince me to stress "activities to reduce risk of disease." We don't do a lot in this country in terms of diet and exercise. We try to do some work somewhat successfully on tobacco avoidance. We need to teach people how to be healthy. And if I were czar of medicine in the United States, I would try to make sure that everybody had a health coach. Many of us go to the gym and we have a trainer. We need trainers to teach us how to be healthy and how to do the right things to stay healthy. That's part of the bottom up. And in terms of costs you know my last paper that I published from the American Cancer Society, I published purposefully, this is my last paper. Ahmedin Jemal who's a wonderful epidemiologist who I happen to have worked with when I was at the National Cancer Institute and again later in my career at the American Cancer Society, I pushed Ahmedin-- he publishes these papers, and we estimate x number of people are going to be diagnosed with breast cancer and y number are going to die. He and I had talked for a long time about how college education reduces risk of cancer death dramatically. If you give a college education to a Black man, his risk of death from cancer goes down to less than the average risk for a white American. There's something about giving people college education that prevents cancer death. I simply challenged Ahmedin, calculate for me how many people in the United States would die if everybody had the risk of death of college-educated Americans. And he came back with of the 600,000 people who die in any given year, 132,000 would not die if they had all the things from prevention through screening, diagnosis, and treatment that college-educated people. Just think about that-- 132,000. Then I started trying to figure out what drug prevents 132,000 deaths per year? And I couldn't think of one until recently, and it happens to be the coronavirus vaccine. Which ironically has shown itself to be the greatest drug ever created in all of medicine. But in cancer, there's no breakthrough drug that is more effective than just simply getting every human being the care from risk reduction and prevention all the way through treatment that every human being ought to be getting. The solution to some of that starts with fixing third grade and teaching kids about exercise, about proper diet. PATRICK LOEHRER: We're going to have to wind things up here. But real quickly, a book you would recommend? OTIS BRAWLEY: Skip Trump, who's someone that we all know, wonderful guy used to run Roswell Park Cancer Center, just published a book actually it's coming out in September called, Centers of the Cancer Universe, A Half Century of Progress Against Cancer. I got a preprint of that, and it is a great book. It talks about what we've learned in oncology over the last 50 years since Richard Nixon signed the National Cancer Act. Keep in mind, he declared war on cancer on December 23, 1971. So we have an anniversary coming up in December. PATRICK LOEHRER: I want to close. Another book, I read the autobiography of Frederick Douglass. It's a wonderful read. It really is good. There were some endorsements at the end of this book, and one of them was written by a Benjamin Brawley, who wrote this review in a book called, The Negro in Literature and Art in 1921. And Benjamin Brawley was writing this about Frederick Douglass, but I would like to have you just reflect a moment. I think he was writing it about you, and I'm just going to read this. He basically said, at the time of his death in 1895, Douglass had won for himself a place of unique distinction. Large of heart and of mind, he was interested in every forward movement for his people, but his charity embraced all men in all races. His mutation was international, and today, many of his speeches are found to be the standard works of oratory. I think if your great, great grandfather were here today, he would be so incredibly proud of his protege, Otis. And it's such a privilege and pleasure to have you join us today on Oncology, Etc. Thank you so much. OTIS BRAWLEY: Thank you. And thank both of you for all the help you've given me over the years DAVID JOHNSON: Great pleasure having you today, Otis. I want to also thank all of our listeners for tuning in to Oncology, Etc. This is an ASCO educational podcast. We really are here to talk about anything and everything. So we're looking for ideas. Please, if you have any suggestions, feel free to email us at education@ASCO.org. Thanks again, and remember, Pat has a face for podcasts. [MUSIC PLAYING] SPEAKER: Thank you for listening to this week's episode of the ASCO e-learning weekly podcasts. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

Oncology, Etc. is a monthly ASCO Education podcast exploring topics in oncology through interviews with emerging thought leaders, physicians, and innovators. In this episode, hosts Dr. Patrick Loehrer (Indiana University), Dr. Jamie Von Roenn (ASCO), and Dr. David Johnson (University of Texas) discuss the importance and impact that friendship has made on their careers. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 8/3/2021 TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. PATRICK LOEHRER: Hi, I'm Pat Loehrer. I was born in Chicago, moved to Indianapolis when I was in high school, went to Purdue University, went to Rush Medical College, came here to Indiana University. And I've been on faculty ever since. I'm now a distinguished professor and the former head of our Cancer Center and Director of our Centers for Global Oncology. JAMIE VON ROENN: So hi, I'm Jamie Von Roenn. I'm a medical oncologist and trained at Rush with Pat and subsequently stayed in Chicago at Northwestern and came here to ASCO as the VP of Education about eight years ago. DAVID JOHNSON: Hi, I'm Dave Johnson. And I'm in Dallas, Texas. I'm a medical oncologist originally from Georgia, spent a large part of my career on the East Coast and in Tennessee before relocating to Dallas to become Chairman of Medicine in 2010. I stepped down from that position last year and now serve as an elder statesman [INAUDIBLE]. So we are excited to be here today for a new endeavor sponsored by ASCO, a podcast entitled Oncology, et cetera and with a heavy emphasis on the et cetera. We are here to talk with thought leaders, physicians, authors, innovators in oncology and beyond. To be honest with you, we have a lot of interests. And so I'm going to turn to Jamie and ask Jamie, why are we doing this? Jamie is the instigator behind this. So Jamie, why are we doing this podcast? JAMIE VON ROENN: So I think the primary reason we did this is to remind people why they chose oncology, that all three of us are people who are super excited about this profession, about what we've learned and what we've given and how we've shared it with each other and with the profession in general, that it's the science. It's the relationships. It's change. And it's incredibly fulfilling on all of those levels. DAVID JOHNSON: Yeah, Pat, what are your thoughts? PATRICK LOEHRER: When Jamie asked us to do this, this was something that we jump at. I love Jamie dearly. Dave and I both share this mutual admiration society. I deeply admire Jamie. And, to do something with Dave who is one of my closest professional friends, this was just a great opportunity. We thought in our conversations, though, as we talked with other people, that it would be good just to talk among ourselves and particularly about the notion of friendship and what it means to each of us personally with the idea that maybe those listening might reflect on that in their own lives. DAVID JOHNSON: Yeah, so you mentioned-- you made a distinction there, Pat. I'd like to know what that distinction represents. You said you had your personal friendships and your professional friendships. How do those differ? PATRICK LOEHRER: Well, you know, I'm not sure how it is for you, but my wife is outside of medicine. I've known her. I had my first date with her 50 years ago. And I have friends that I really don't like to talk about business with. I just talk about other things, our kids, family, whatever. Our friends in medicine are a little different. We have deeper conversations about our work. And there are certain aspects of our work that I think touch us personally. We have patients that we've become close to that are rough. And, many times, I don't share those interactions with my friends at home because it's just not important to them. So I treasure especially you guys, I treasure deeply. We've shared a lot over the years. JAMIE VON ROENN: So it seems to me that friendships in general are built on shared experiences and that the experiences in medicine are so different from anything else. And, if you don't have friends in your profession, you may not actually have the opportunity to share and sort of have a sounding board for how difficult things are sometimes in spite of how inspiring it is. DAVID JOHNSON: Yeah, I think I like your distinction. Both of you pointed out the shared experience. The world of an oncologist, viewed from the outside, may appear to be a rather morbid specialty, but, in fact, it's one that I personally find incredibly rewarding. But there are those moments that are challenging and difficult-- patient encounters, professional setbacks, et cetera. And it's nice to have someone within the profession itself that can relate to those experiences, especially failure. I know, Pat, you've had lots of failures. [LAUGHTER] JAMIE VON ROENN: I think we all have. PATRICK LOEHRER: Thank you. Just as a background, there have been, in this group, five runs for ASCO presidency. And only one of them has been successful. So yeah, we know failure, Dave. JAMIE VON ROENN: But I think it's important because no one is successful all the time. And it's your friends who actually get you through that and let you see, OK, yeah, I'm still OK. And I think it's the other side of that too. Everyone who's honest has suffered from the imposter syndrome. And it's your friends you can openly share that with. And it helps you go the next step when you're struggling. DAVID JOHNSON: So you mentioned that the two of you met during your residency training. What prompted that friendship then? And how has it been sustained over the last many years? I won't say the number of years, but a lot of years. JAMIE VON ROENN: So we actually met when I was a medical student, and Pat was my intern who I worked with. And then, when I was an intern, Pat was the resident. DAVID JOHNSON: So that accounts for all your problems in the medical field? JAMIE VON ROENN: It accounts for how well trained I am. DAVID JOHNSON: I see. JAMIE VON ROENN: But I think it was the sense of joy in the profession that probably connected us and a love of people. I don't know. Pat, what would you say? PATRICK LOEHRER: Well, it was a special time back then in medicine. Our particular hospital was a resident-run hospital. I think we acted first and then asked permission from the attendings later on. And it was really very special. There's a lot of people from Rush who have gone into oncology in many different areas. And so it was very special. Jamie I knew. We really did not keep in touch until she gave a plenary paper at ASCO. And I remember writing her a note. And I was so proud to see her up there. And I wrote that in a note. And we started, basically, communicating and getting together regularly. And so, each year at ASCO, as you know, we get together, the three of us, collectively or individually, and have a dinner. It's really the highlight of the meetings for me. DAVID JOHNSON: Yeah, I mean, I had the good fortune of Pat and I coming together, I think, shortly after I completed my fellowship. And Pat and I were both starting our academic careers, he at IU and I at Vanderbilt at the time. And we interacted through one of the major NCI cooperative groups that, unfortunately, no longer exists. It may have been due to our work, Pat, that caused the Southeast group to divide. But it was through Pat that I met Jamie. And so that's been really one of the most rewarding relationships that I've had professionally over the last, now more than 40 years. I mean, it's been a long time really. PATRICK LOEHRER: And we were on the ABIM together, the three of us, which was a riot. It's another one that seems like a thankless position, but we realized how hard it is to write very good questions. And we would spend a lot of time together doing this. I learned tremendously from the two of you and the others around the ABIM. JAMIE VON ROENN: Yeah, that was a remarkable experience for us because it's a small group of people putting their ego outside the door and working together. DAVID JOHNSON: And the challenge of maintaining one's knowledge base, I mean, honestly, I hadn't thought that much about it until I was invited to join the ABIM. And thank you, Pat, for making that possible. I consider it one of the highlights of my professional career is being a part of that. And I realize how controversial the work that ABIM is doing today, but, still, I think it was a wonderful experience. JAMIE VON ROENN: We've been pretty lucky to share multiple professional activities. I mean, when you were president, Dave, I was on the board. We shared ABIM. We shared some ECOG work way back. It's been a lovely crossing of paths beyond friendship . DAVID JOHNSON: Yeah, I mean, I think one piece of advice that I give to residents, and especially those who are interested in heme-onc fellowship, is find a friend. It's really important that you do so. I was fortunate to have the two of you and some other friends during the course of my career. And I must say, turning to a friend for advice, for assistance, for mentorship-- I can't remember who said it first. Having a friendtor is really, really important in the course of one's professional development. JAMIE VON ROENN: It's an important message because it takes time. When people are in training, they often think they don't have time, but this is a value on every level. It's more than worth the time. PATRICK LOEHRER: I just want to jump on that friendtor. We all have had people that we work closely with. In Indiana, it's been Larry Einhorn who was a role model for me when I was a medical student and then became a mentor when I was a fellow at a junior faculty. And he is, again, one of my closest friends. And he is one that gives me advice, but also just listens. And, similarly, he'll come in and ask me advice, which was mind boggling that someone of his stature would lean on us. But I was trying-- I was just going to put a caveat or a corollary to your statement about finding a friend. Dave, what I tell people, I think it's more important to be a friend than to have them. I think, if you get into the habit of helping other people and being a friend, you'll collect people close to you down the road, but, boy, it's not a one-way street. It really has to be the best friendships in which you give and you also happen to receive, but it's really a nurturing process. It just doesn't happen by chance. It happens because the people make an effort in it. JAMIE VON ROENN: Absolutely. DAVID JOHNSON: So what do you look for in establishing those friendships, Pat? What attracts you to an individual to even consider establishing a friendship? PATRICK LOEHRER: Well, I like to have friends who are dumber and uglier than I am. And that's why I really migrated to you. I mean, I think, when I looked around the room, I said, this guy could be my friend. DAVID JOHNSON: It's amazing. I saw myself in the mirror when I saw you. JAMIE VON ROENN: So I'm going to take that more seriously and say I think what we have done with each other is looked for people with values that connect and that, in the end, whatever those values are, that's what makes the friendship last. PATRICK LOEHRER: Well, it's interesting. As we talk about, in academics, one might think that you become friends with people in your own disciplines, but Jamie was a age researcher in palliative care. Dave, you were a thoracic oncologist. And I was a GI. And the loneliest friendship would be with thymoma people. But none of us really merged together because of our own professional disciplines. It really was something else. I think there was a higher power that pulled us together. DAVID JOHNSON: Oh, I think Jamie touched on it. I mean, it's the values that we share, I think. And I'll go back to something we talked about earlier, which is our shared love of the profession itself. I think I was 10 years old when I first seriously thought about being a physician. You may argue that a 10-year-old can't think seriously about anything, but, throughout my youth, all the way through college and, ultimately, medical school, medicine was my goal. And I've never regretted making that decision. I know there's a lot of unhappiness in the medical profession in this day and age and a lot of talk about burnout. One recent study actually even suggested that over half of all physicians would not recommend medicine to their children as a profession. I find that disheartening. I'd be delighted if my child were to choose such a profession. She didn't, but I would have been delighted had she done so. And I know, Pat, you have children who have pursued medicine as a career. PATRICK LOEHRER: Yeah, I was-- actually, at my son's graduation, I was up in the balcony away from everyone else taking photos, but I did find myself with a tear coming down my eye watching him just because it was an affirmation that my life was something that didn't steer him away from medicine. I think he did find, in my life, the joy that you can find in this profession. I want to change this a little bit to you guys, Dave, because you talked about the profession. And, several years ago, well, you both have had some really tough episodes in your life, but, Dave, you came down with lymphoma many years ago. And I do remember an ASCO presentation that I think Jamie helped put together in which there were several of you. I think Nick Vogelzang and Sandra Horning were up there. And you shared your experience of having cancer and shared some of the stories, I think, of friendship. But I do remember the phrase that you used at the end of the talk about how you had a deeper appreciation about the majesty of our profession. That's always touched me, but can you reflect a little bit about your illness and having lymphoma as a cancer doctor and what you learned in terms of this topic of friendship? DAVID JOHNSON: Well, we, as oncologists, think we know what it's like to have a serious illness. And I certainly was no different than most oncologists. But, when I myself was diagnosed with a malignancy, I must say, I had many of the emotions that I've witnessed in my patients. And, also, suddenly, my brain went completely blank. I couldn't think about what it was that needed to be done. And I, like most patients, began searching for the perfect answer. How would I deal with this? But I was also curious because, a few years prior to my own diagnosis, another faculty member at the institution where I was at the time had been diagnosed with ALS. And he wrote a very personal and moving piece that was published in The New England Journal about his experiences at that institution and how he was treated by his fellow physicians. And, actually, what he had to say was not all that complimentary in some instances. And I wondered myself how I would be dealt with by my fellow physicians. And I must say, my experience was virtually the polar opposite. I was surprised, honestly, at how heartfelt the good wishes were, the way that my colleagues went out of their way to try to make sure that I was successfully treated, was dealt with appropriately, even colleagues at my institution that I had not known that well finding excuses and reasons to drop by the office that seemed manufactured, quite frankly, but were clearly, again, intended to lift my spirits and make me feel positive about my future. It really made me realize just what a special profession we're in and then, to have friends that I could turn to, such as you and others, who really did a lot to lift my spirits. So, when you see that, you can't help but be really moved by the men and women who come into this profession and particularly those who choose oncologist as a specialty. PATRICK LOEHRER: I had a colleague who succumbed to glioblastoma. And he was-- when he was first diagnosed, he told me there were three kinds of friends, he realized. There were the long-lasting friends that he's always had. There were people who he thought were friends who kind of just faded away, mainly because they didn't know what to say. And then the third group were these unexpected friends, people that he didn't really know that very well, but came into his life and really made a difference. It was very insightful. DAVID JOHNSON: Yeah, I mean, that's exactly the experience I had as well. And the group that unexpected was perhaps the most surprising to me, but really I came to appreciate greatly. PATRICK LOEHRER: Many years ago, when we were doing the board questions, Jamie was not able to come because her husband Kelvin had been diagnosed and then, shortly thereafter, passed away from cancer. I knew him when I was a resident. He was a feared neurosurgeon. He made Ben Casey look like Dr. [INAUDIBLE] He was an incredibly intense, wonderful man, but I've not talked much deeply about that. And, with some reluctance, Jamie, I don't know if you want to share a little bit about how you felt as a palliative care doctor, and then here's your husband who's dying of cancer. JAMIE VON ROENN: Sure. And it kind of echoes what both of you have said. Here I was, a palliative care doc. And I thought I understood what death and dying was about. And, after Kelvin died, I was blown away. And I recognized, I said the right things, but I never really understood them. And it changed the way I talked to patients forever. And I too had the same experience of friends who are new, old, and otherwise, those that disappeared because they were too uncomfortable. And I was shocked that there were partners, oncologists, who could never ever say anything to me because they were too uncomfortable talking about death. And here it was something they were supposed to be trained to deal with. And, in fact, I remember, many times, Pat, you calling and checking in on me. And I remember in particular one day when I was down, and you said, wow, you are in a dark hole. And I was. And it took a long time, but it's friends that get you through and the ability to talk about what nobody wants to hear that helps you recover ultimately and move on. And those are life friends, but there's something different about people like the two of you who understand these experiences from a different perspective. DAVID JOHNSON: Yeah, I mean, I think these shared experiences, they're not shared in the sense that we experienced it personally, but the fact that we were able to relate to one another and share those very personal moments only fortifies and solidifies an existing friendship. And there are a lot of people I would not have that discussion with, but there are a few. And you are certainly among those two that I would. PATRICK LOEHRER: Well, I mean, you guys mean a lot. And I know-- I'm trying to think of the time. Back when I was thinking about becoming a heme-onc division chief. I gave Dave a call. Dave was head of heme-onc at Vanderbilt, I think, for 68 years or something. I can't remember. You were there for a long time. And I called him up. And I thought for sure there would be this, yeah, Pat, you'd be great. You'd be a wonderful division chief, but there was just this silence. It was like, I don't know, about 90 seconds of just pure silence. And then you said, yeah, it's mostly a good job. Then you reflected a little bit about this. And, in terms of this rejection, I think the other thing you taught me is it's OK not to be the first choice. But I can't remember. What choice were you for the division chief? DAVID JOHNSON: 11. PATRICK LOEHRER: 11. Yeah, I love that. I love that. DAVID JOHNSON: That's true. I mean, they interviewed 10 people before I was offered the job. So I knew I was in the top of all candidates. PATRICK LOEHRER: Top hundred, huh? This is like Rock and Roll Hall of Fame [INAUDIBLE]. DAVID JOHNSON: They ran out of candidates. PATRICK LOEHRER: Well, you know, that part, I've got to be honest with you. The stories with you guys have helped me out quite a bit because junior people would look up and say, oh, look at these guys. Aren't they successful? But they don't realize that we have stumbled and failed over the years in many things. And the best thing you can do is just laugh about it when you try. But, going back to the notion of friendship, there is no greater joy than I have is to see you guys, who are my friends, succeed. And a definition, I think, of a friend, at least a minor definition, is, when someone gets an award, that you find greater joy in them getting the award than you would if you got it yourself. If you find yourself kind of jealous and wondering, well, I wish I had that, probably, it wasn't your friend then. But I've gotten so much joy in watching you guys succeed. JAMIE VON ROENN: So I think there's a corollary to being a good mentor, which is, when your mentees surpass you, then you were successful. And it's the same with friendship. PATRICK LOEHRER: I'm one of the most successful people in the world then. DAVID JOHNSON: I was getting ready to say, I think we've all succeeded wildly then. [LAUGHTER] JAMIE VON ROENN: But that is the goal. I mean, what's the point of being able to help people if you don't make them the next set of stars? DAVID JOHNSON: We've been lucky to have a lot of really terrific men and women who we've been able to work with over the years and call them mentees, but, in reality, we've been their mentees. They've been the ones that have taught us so much. I'm very proud of all of them. JAMIE VON ROENN: Yeah, I think that is something to be proud of. And, when I look back, it's those things that make me most excited about what I've accomplished. PATRICK LOEHRER: Well, I think, every good relationship, you really get more out of it than you get into it. Even as we have our heart to hearts with our patients and having end of life discussions, I usually get so much out of that in a reflection of their own personal love for each other and their family and what they treasure in life. But, again, with you guys, unabashedly, I'll say this in public. I love you deeply. And I appreciate your friends. CS Lewis had a book called The Four Loves in which the most unnatural of the four loves was friendship, but it's what he actually thought was probably the most important one because it's so unique. And it's not expected, but you guys, I think, are an important part of my life. And I thank you for that. JAMIE VON ROENN: I love you both and feel the same. It's the luckiest thing there is. DAVID JOHNSON: Yeah, absolutely, absolutely. Thank you so much for that. Well, I think our time is about up for today. I want to thank all the listeners. I'm sure there's tens of thousands listening to this. Well, I just called Pat's friends and told them listen. So we plan to do this monthly. We already have a scheduled guest for our next podcast. It'll be Dr. Otis Brawley who I think many of you know by reputation, one of the leading luminaries in oncology in the United States. He's now at Johns Hopkins. I think it'll be a really enlightening and fun conversation to hear what Otis has to say about the current state of oncology in this country. So, with that, we'll sign off until next month. Thanks, everybody. [MUSIC PLAYING] SPEAKER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive eLearning center at elearning.asco.org.

The incidence of colorectal cancer among people under 50 is rising. In this ASCO Education podcast episode, medical oncologist Nilofer Azad (Johns Hopkins Medicine) and epidemiologist Caitlin Murphy (UT Southwestern Medical Center) discuss risk factors, screening, and treatment. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 7/28/2021 TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. NILO AZAD: Welcome to the ASCO learning podcast episode focusing on early-onset colorectal cancer. My name is Dr. Nilo Azad, and I'm a medical oncologist and Associate Professor of Oncology at Johns Hopkins Medicine. I'm joined today by Caitlin Murphy, an Assistant Professor of Epidemiology at the University of Texas Southwestern Medical Center. We wanted to start today with a patient case, just to give a little bit of context about the kinds of patients that we are dealing with. A year ago, a patient presented to my clinic who was 32 years old. She was having significant symptoms of rectal obstruction. She was having trouble going to the bathroom. Her bowel movements were difficult. She was having bloody stools, and she had gone to see a gastroenterologist who had done a colonoscopy, biopsied her tumor, and found that she had adenocarcinoma of the rectum. Now, luckily, at that time, she didn't have any metastatic disease. But her tumor was quite large, 15 centimeters in size, and so we decided to move forward with doing chemotherapy in the neoadjuvant setting. She got aggressive chemotherapy with FOLFOX for three months. And when we did a scan, unfortunately, we found that the tumor had grown. Now, she still didn't have any disease outside of the rectum but, during that time, we had gotten some molecular testing back which showed that the patient had mismatch repair deficiency or microsatellite insufficiency. So we decided to try something a little outside of the box at that time, where we started treatment with immunotherapy. She had a dramatic response to immunotherapy. Her tumor shrank. And, six months later, she went to surgery and, though on scan it still looked like she had a large tumor, it turned out that that tumor was only scar and that she'd had a complete response. She came back to see me, last week, in clinic. She looks fantastic, and she's moving forward with planning for a family with her husband. So, Dr. Murphy, can you tell us a little bit about the trends in early-onset colorectal cancer incidence in the US and globally? CAITLIN MURPHY: Of course. I'll start, first, by talking about trends in early-onset colorectal cancer in the United States. Incidence rates began increasing here in the early 1990s and have nearly doubled over time, from about eight cases per 100,000 persons in the early 1990s to 16 per 100,000 persons in today. The largest increases have occurred in 40 to 49-year-olds. They account for about 80% of all cases. And we've also noticed that incidence rates of rectal cancer versus rates of proximal colon or distal colon cancers have been the largest increases in incidence. We've also seen a similar increase in local and distant stage disease. And, to me, one of the most compelling observations that we've made is that incidence rates have increased successively across generations, or about the year that you were born. There's a very clear and marked increase in incidence rates starting with persons born in and around 1960, or who we sometimes call Generation X. Epidemiologist like to call this a birth cohort effect because essentially we see incidence rates increasing across birth cohorts. More recently, we've observed that incidence rates have started actually increasing in people in the early 50s, the 50 to 54 age group, and this really does not appear to be driven by early stage disease as we might expect with more screening in that age group. But perhaps the increase in this early 50s age group is driven by the same things happening in people under the age of 50. Globally, we've seen a similar increase occurring in countries that have colorectal cancer screening and even in countries that don't have colorectal cancer screening. There was a recent analysis of 36 countries, and it found that incidence rates have increased in 19 of those 36 countries. Nine of those countries had stable or declining trends in incidence in older adults. There really wasn't a clear pattern among those countries in terms of the degree of Westernization or income level that might explain those trends. And, importantly, that birth cohort effect that I mentioned as occurring in the United States, where we see increasing incidence rates starting with Generation X, has also been reported in many other countries, including Canada, Australia, and some East Asian countries. NILO AZAD: And, Dr. Murphy, what is the current thinking regarding causes of this increased incidence of colorectal cancer that we're seeing in young people? CAITLIN MURPHY: Generally, there are two schools of thought about what's going on here. The first thought is that this is the same disease that's happening in older adults, but it's just now occurring at a younger age. For example, we've seen a steady rise in factors that we know increase the risk of colorectal cancer in older adults, like obesity and diabetes. And, these factors, we also know are now increasingly occurring at a younger age. But many of my clinical colleagues like you, Dr. Azad, tell me that most of the patients they diagnosed with early-onset colorectal cancer are otherwise fit and healthy and have no obvious risk factors like those. And so this second school of thought about what might be going on here is that this is really a different disease than what's happening in older adults, driven by as of yet unknown risk factors that have also increased in the population. NILO AZAD: Yes, I definitely feel like that the cohort of patients that I see in my clinic-- and, of course, at a place like Johns Hopkins, we see a little bit more of a skewed cohort in terms of seeing more younger patients-- that most of them aren't people that I would traditionally look at and say that they've got a risk factor that explains the situation. What are the main risk factors for early-onset colorectal cancer? CAITLIN MURPHY: There's still a lot of research to be done in understanding what the risk factors for this disease are. And I like to think of the risk factors that we know about as affecting early-onset colorectal cancer as falling into one of four sort of categories. The first category is having a genetic predisposition, so either having a family history of colorectal cancer or even a family history of an advanced adenoma or having a hereditary syndrome like Lynch syndrome or polyposis. Together, these account for about 40% of all new cases and many of the cases that don't have a traditional phenotype or mutations associated with colorectal cancer. So, for example, many of the patients we see with Lynch syndrome don't necessarily have the typical phenotype that we've expected to be associated with Lynch syndrome over the past however many years. The second category is what I like to call established risk factors. Or maybe another way to think about this is usual suspects, so already known causes of colorectal cancer in older adults. I mentioned these earlier, obesity, diabetes, but then there's also smoking, physical activity, and sedentary behavior. Then the third category is what I call early life factors, and the importance of understanding early life factors is really driven by the fact that incidence rates have increased by generations. Remember that first cohort effect I was describing to you earlier. This birth cohort effect tells us that risk factors in very early periods of life or vulnerable periods of growth and development are important. It also tells us that we should rethink some of those usual suspects or established risk factors as occurring very early in life. For example, instead of just thinking about obesity, thinking instead about birth weight or childhood obesity as well as growth trajectories in infancy. And then, finally, the fourth category is unknown risk factors. So the trends in incidence point to some clues, whether things in the population have increased over time or by generation, that might help us understand what's going on here. Some examples of those unknown risk factors might include environmental chemicals like flame retardants or endocrine disruptors, antimicrobials, or other infectious agents. And there really has been no research on these unknown risk factors but, again, people think that these might be related to early-onset colorectal cancer just because the trends in their prevalence have mirrored the trends in incidence. NILO AZAD: So, Dr. Murphy, you've really laid out wonderfully both the risk factors that we're seeing in some of these younger patients and then just the changes in incidence and occurrence as well. So how has that affected screening guidelines, going forward, as well? CAITLIN MURPHY: In 2018, the American Cancer Society recommended lowering the age to initiate average risk colorectal cancer screening from starting at age 50 to age 45. At the time, when this was done, all of the GI societies and the United States Preventive Services Task Force recommended still continuing at age 50. This recommendation from the American Cancer Society was a qualified recommendation, meaning that it's based on simulation modeling and not necessarily empirical evidence driven from randomized trials or other clinical studies. More recently, just last fall, in 2020, the United States Preventive Services Task Force released a draft recommendation to do the exact same thing, so lowering the screening age for average risk people from 50 to 45. The idea of a draft recommendation simply means that they put the recommendation out there for public comment and then consider some of those comments before either revising that recommendation or making the recommendation official. Like the qualified recommendation, initiating average risk screening at age 45 has a grade B recommendation from the task force, meaning that they have fair compared to strong evidence to support that recommendation. And I expect that we'll be seeing a final one coming this spring or summer. NILO AZAD: Is there anything unique about colorectal cancer in young patients biologically? CAITLIN MURPHY: That's a good question and something we still don't know a lot about. I'll just give one example of that. We know from certain studies that early-onset colorectal cancer seems to be enriched for certain molecular subtypes like an immune subtype, although the research in this area is really limited by a small number of studies. And most of the studies have been conducted just as a single center and not at the population level. NILO AZAD: And how do our patients that are younger do in terms of survival, compared to their older cohorts? CAITLIN MURPHY: Most studies that have looked at this report no difference in survival between younger and older patients with colorectal cancer. We do know, however, that younger patients are more likely to be treated aggressively with surgery, multimodality chemotherapy, and/or radiation therapy. This really raises an important question. If younger patients have no survival advantage despite more aggressive treatment, this could mean that younger patients have tumors that are more aggressive or that they respond differently to treatment regimens that have been developed for older patients with colorectal cancer or risk disease are over treated. With that in mind, I want to revisit our patient case, the 32-year-old woman with rectal cancer. Dr. Azad, what should be discussed with a young patient before starting therapy? What kind of testing needs to be done? NILO AZAD: So when we have young-onset colorectal cancer, just as you mentioned, there are a subset of these patients that have a genetic predisposition to developing colorectal cancer and other tumors as well. And so these patients absolutely need to be assessed for these genetic syndromes. So for my patient, in particular, I mentioned that she had mismatch repair deficiency or microsatellite instability. That suggests that she had what was called Lynch syndrome. And Lynch syndrome is something that, now, luckily, we actually have therapies for in terms of having immunotherapy. But knowing about that kind of a syndrome is important for this patient for her future planning, for the other tumors that she might develop, and of course for counseling for the rest of her family as well. And what was actually interesting about this case was that she had traditional mismatch repair testing with immunohistochemistry of her tumor, and that testing came back that she had microsatellite stable disease. So initially we actually didn't think that she had microsatellite instability. But because her family history was such that I was still suspicious that this was true, we sent second testing using a different kind of assay, and that's where it became clear that she had mismatch repair deficiency. So it's really important to maintain a high index of suspicion and recognize that even some of the tests that we send are not perfect and, if you still have a high index of suspicion for reasons like the family history or a patient having a second cancer previously, that you should follow that instinct and make sure that you're doing as deep testing as necessary. The other issue, of course, with younger-onset colorectal cancer, especially for people as young as my patient was, is the question of fertility. And so because she had rectal cancer and, as part of the paradigm for rectal cancer, these patients will have radiation, she was not going to be able to carry a fetus or embryo to term after completing therapy. So that's something that we need to understand early, have those conversations early, and get a multidisciplinary team involved that usually involves fertility experts as well as gynecologists. And so, for her, what we ended up doing was doing an egg harvest. And then she had in vitro fertilization performed, and then they were able to store embryos for her and her husband. And now they're actually looking forward to moving forward with surrogacy. CAITLIN MURPHY: So it sounds like your patient had to navigate a lot at the beginning of her diagnosis, considering fertility options, grappling with a new diagnosis at the age of 32, and then going through all of the workup and diagnostic testing. After that, what kind of treatment options would be appropriate for her? NILO AZAD: So, at this point, we actually aren't treating early-onset colorectal cancer any differently, in terms of how we actually treat the cancer, compared to people who develop colorectal cancer at a more average age. That said, our patients do have specific needs that we need to incorporate and discuss, both when they're diagnosed and as they start treatment and then later as they complete treatment and for their survivorship. So, clearly, we talked about the fertility issues. But when you've got a patient who's in their 30s or 40s and they're undergoing chemotherapy that's going to leave them with potentially lifelong neuropathy as one of the long-term side effects, that's really something that we need to discuss with patients, both so that they know about it, but what impact could that have on their professional function. For example, this week, I saw a 40-year-old woman who is newly diagnosed, and she is actually a concert musician. And so the idea that this may actually result in meaningful disability for her for what her chosen profession is, it's something that we need to discuss with these patients because they likely have 20 or 30 more years of professional life that is ahead of them and makes a huge difference for them, and financially as well. And, on that front, when you are treating people who are kind of in the prime of their life when it comes to their earning potential, that's also a really big issue that needs to be discussed. Sometimes people, in fact, lose their jobs because of the amount of time that they have to take off for treatment during that time. And so working with social work and making sure that we are addressing these issues and not just focusing on the things that are physical is really important. I'm a believer that impact on sexuality and body impact is not something that is only for the young. But, clearly, that's something that we need to discuss for all ages of patients when it comes to the kind of therapies that we have, especially with rectal cancer where, a lot of times, patients are left with a temporary or permanent colostomy. And I also think that there is some real issues around feeling isolated from your peers. It's still very rare to develop colorectal cancer, or any cancer, below the age of 50. And so because of that, even though we are seeing an increase in incidence, a lot of times, this is an area where patients can really have significant mental anguish because they feel so isolated from their peers that aren't having to deal with these issues. So I think all of these are really important features of dealing with early-onset colorectal cancer. CAITLIN MURPHY: I think you said it exactly right, that these patients are in the prime of their life and not necessarily just navigating cancer treatment-related factors, but also having to deal with family and care-giving responsibilities, their job, their economic situation, and their social situation. If all other disease factors and patient characteristics were similar, though, but the patient that you talked about was older, let's say, aged 55, would you do anything different in terms of her care? NILO AZAD: So, you know, with that particular patient, we were trying very hard to see if we could find a way that she might not have to have radiation because we knew that radiation was going to take away her fertility. And so when she had that initial progression on chemotherapy, what we did was a little bit out of the box, at that point, using data that existed in the metastatic setting showing that immune checkpoint therapy was very effective in patients with mismatch repair deficiency and treating a patient that didn't have metastatic disease, hoping for an excellent response, which is what we got. Now, fortunately or unfortunately, while she had a fantastic response, because the tumor didn't regressed completely and left her with that scar tissue, she did end up getting radiation because we couldn't be confident that we had gotten a complete response with just the immunotherapy. But I do think that, with younger onset colorectal cancer, what often happens is that we dance a little outside of the box in terms of trying to do things that would help preserve patients' fertility or preserve some of their overall function that might be a little bit different than what we might do for people 20 or 30 years older. I think that, in the right circumstance, that can be the right thing for our patient. But it is something that you have to do very carefully because, as you mentioned, it may well be that sometimes our younger patients are being treated more aggressively than they need to be just because they come in, and they have less comorbid conditions. And people feel comfortable being more aggressive when they might not need it. CAITLIN MURPHY: This is a really great conversation. And, as an epidemiologist, I often get lost in the numbers and forget about the real impact that this disease has on patients. And so I really appreciated learning about the patient case. NILO AZAD: Thank you, Dr. Murphy, for joining us as well. I think that this is such a great way for us to put some of those really objective data together in terms of what we're seeing with more patients that are developing young-onset colorectal cancer; what groups that we're seeing that in, both in terms of ethnic groups and risk factors; and then combine it with some of the key features that are important in terms of patient care, which I would say means that all patients should be getting genetic testing, all patients should be treated aggressively, and that there are many both physical and psychosocial factors that we need to be taking into account when we're treating our young-onset colorectal cancer patient. So thank you so much for your time. I've really enjoyed talking about this with you. [MUSIC PLAYING] SPEAKER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive eLearning Center at elearning.asco.org.

The ASCO Education podcast continues the conversation on burnout, this time with a focus on how it affects trainees. This week's episode features Drs. Anna Laucis (University of Michigan) and Daniel Richardson (University of North Carolina). If you enjoy this episode, please subscribe or leave a comment. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 7/14/2021 TRANSCRIPT [MUSIC PLAYING] ANNOUNCER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] ANNA LAUCIS: Hello. And welcome to ASCO Education's podcast episode focused on the important and far-reaching effects of burnout among oncology trainees. My name is Dr. Anna Laucis, and I'm a radiation oncology resident physician at the University of Michigan. DANIEL RICHARDSON: And I'm Dr. Daniel Richardson. I'm an assistant professor and leukemia doc at the University of North Carolina. I recently completed my hematology-oncology fellowship here at UNC as well. ANNA LAUCIS: So, Dr. Richardson, what has been your personal experience with burnout in your medical training and your current professional role? DANIEL RICHARDSON: Well, that's a great question and something that I'm excited to talk about today. So burnout can really be expressed and experienced in numerous ways. Traditionally, we've segmented-- excuse me-- this into categories of emotional exhaustion, cynicism, and feelings of inefficacy. And one of the first things to mention is really the structure or the practice of medicine itself. I really see in most places that medicine continues to be very hierarchical and rigid. And this hierarchy and rigidity can lead to depersonalization. I feel like we have a tremendous opportunity to connect with patients so many times in their darkest days, but we're taught that we can't show vulnerability and we need to act in a certain way. We are conditioned really to place boundaries around ourselves to depersonalize as a way to get through rounds, as a way to improve efficiency. I know you've probably experienced this, but on the inpatient wards on morning rounds, we go from room to room. We listen to patient stories about the devastation that cancer has caused on them, but we don't talk about it, and we don't allow empathy really to come with us into rounds, and we exclude emotions altogether. I think about, as a leukemia doc, the challenges when some of my patients die, and we don't talk about that. We don't talk about those challenges. We don't talk about our own emotions as we go through that process. And I often comment to others that I walk through the Valley of the Shadow of Death with most of my patients, and this human connection that we can have in the midst of that is so important. It's truly a sacred space where we can invite our patients into. And this process of walking with patients through that can bring about great meaning and satisfaction. ANNA LAUCIS: Yeah. I fully agree. I think there are many ways in which we connect with patients. And I think that's really important, as oncologists, whether radiation oncologists or medical oncologists or surgical oncologists, is the ways in which we connect and empathize with our patients. It's not only, I think, the greatest gift and support we can give to patients, but also I think, unfortunately, can also really lead to burnout, especially it's difficult to set boundaries sometimes. We really invest in our patients, and we almost take personal responsibility for their outcomes as well, even though, as I've gotten further in my training, I've realized that, unfortunately, there's just really bad biology sometimes, just really bad disease. And as much as we do, there is a limit to what we do. And I think that, as I've gone through my training, I recognize that being able to set boundaries, however difficult that is, while still empathizing, having a way to find meaning and purpose outside of work is so important as well and can help reduce that burden of burnout. And one of the ways I've conceptualized this is we absorb these collective traumas, as you mentioned, walking from room to room in the hospital ward, for instance, in the clinic in radiation oncology. But going from room to room, I try and take a second, and whether it's washing my hands or just taking a moment to reframe, it really helps to set that boundary not only between the patients and ourselves but also between patient to patient, because it is so important that we give as much as we can to our patients but also that we find ways to refurbish and refill this bucket of energy and dedication that we have. DANIEL RICHARDSON: Yeah. I think your point about finding identity in your job, I think is-- it's both a double-edged sword. I'm a huge proponent of finding meaning in medicine and then really finding ways for us as a community to find meaning in medicine. But also, if we find our whole identity in our work, it's really going to become an idol in our lives, and it's going to inevitably fail us. I think trying to use work alone to sustain our deep need and purpose as a human being is probably not enough. I find that work has a place in my life and has a place as, many times, our calling. However, I don't think it can fill every aspect of it. And if we try to put that onto our work, even a tremendous calling such as oncology, it's inevitably going to fail us. ANNA LAUCIS: Absolutely. I agree. And I think one of the things that to keep in mind is that whether I think in medicine in general, but in particular oncology, it really stretches us to our full capacity in training, and we give it our everything. And I think sometimes, as I've touched in conversations with other colleagues, sometimes we give it so much of our all that other elements of ourselves that made us interesting and dynamic and multifaceted in high school, college, medical school, cooking, exercise, all of these things that we do to be a complete person, some of that does, I think, by nature of the intensity of our training, especially in oncology, does get pushed to the side. But I think it's important as much as we can to find ways, even if it's small, even if it's small amounts of exercise or small amounts of cooking or enjoying other aspects of our life, to reintroduce to us when we're able to in training, because I do think it allows us to bring our full selves to work and to connect with patients in the best way we can as well. And I think one of the things that I love the most is being able to bring a smile to a patient's face, even though they are in a very vulnerable time. All of our patients pretty much have cancer. But like for example, the other day, I connected with a patient about going to Harry Potter World and Disney, and that really brought a smile to his face, even though we were dealing with a metastatic cancer for him. But I think that really brings meaning and also is so important to do to be able to connect. DANIEL RICHARDSON: Yeah. So I want to jump off two points. So the first one you said, how do we have these repeated traumas in our lives, and how do we manage those? I think this repeated trauma or this repeated suffering that we experience on as part of our jobs really erodes our ability sometimes to engage into our own lives and engage in the lives of our patients. And I think about as oncologists we often are mediators of life-defining information. We often tell patients that they have cancer, that they aren't going to survive the next couple of years, that they need to make decisions to prioritize as we move forward. And we can feel like we are the mediators of devastation to our patients. And I think, as we've mentioned, one strategy is to build these deep, impenetrable boundaries, where we don't allow that suffering to seep into our souls. Sometimes we talk about resilience, but I think that, as you mentioned, too often, we can hide in our boundaries and not allow that connection to happen. And I think, as you mentioned, these small things that we can begin to do-- we can begin to connect with patients to give them good-- I really think that this is developing a strategy of redemption rather than resilience alone. That is, we can learn how to find great meaning, purpose, and satisfaction of walking through the suffering with our patients rather than simply learning to endure it as a side effect of our lives. And this really comes from embracing, caring for the suffering as a calling, and finding ways to bring good into the lives of patients in the midst of their suffering. So you mentioned talking to them about Harry Potter, getting to know them. Perhaps it is just this listening ear. I think oftentimes patients have a tremendous story to tell, and allowing them to tell it or walking them through it is so important. Perhaps it's a prayer. Perhaps it's a hug. Perhaps it's just the acknowledgment of the loss that they're experiencing and finding those connections with patients and bringing good into their lives in the midst of the suffering that they are experiencing is so important. ANNA LAUCIS: Yeah. I fully agree with you. I think that's one of the greatest gifts that we can give as physicians. And it reminds me of-- so I did a lot of art history in high school, really enjoyed that, very different from medicine. But I think one of the interesting things-- and I'd love to take a specific course some time on just the history of medicine through the lens of art-- it just reminds me of this famous painting of the physician at the bedside of a patient, holding their hand. And in those days-- this was way back in the early times where medicine was really more about just the physician at-- the word "attending" comes from just attending to the patient's needs. And I think that sometimes we get so tied up in learning all the clinical trials or all of the oncology outcomes, but I think that, at the core of it-- and I know that the ACGME has an initiative, Back to Bedside, and trying to find the joy in medicine that I think there's a lot we can offer just as a fellow human, as a fellow person who brings their redemption, hope. And I think it's important to draw the line there, especially in oncology, to not offer false hope, but I think to give as much support as we can to patients, because it is a very vulnerable time. And yeah, I think patients have very interesting stories, just getting to know them, even if it's asking about their family or things that are important to them. Or I try and recognize if patients are wearing a shirt with a logo on it and I recognize that, I try and bring that up, and you often see their face light up. Like, a patient recently loves the Detroit Tigers. And so he was having horrible nausea a bit. Then, talking about the Tigers, his face lit up, and he forgot about the nausea for a moment. And so even just those moments of peace that we can bring to patients, I think that, for me, at least helps combat burnout because I really find a lot of purpose and meaning in that. And I know that, at least in that moment, I gave that patient some peace and some joy perhaps. DANIEL RICHARDSON: Yeah. I think that's really important as we think about our role as co-journer, as people stepping alongside and walking with patients through their journey with cancer. Obviously, we'll have opportunity to experience great joy for some patients and great sadness for others. So I think that is really an opportunity for us to enter into those experiences with our patients. I'm interested on your perspective on how COVID has really impacted your experience of burnout or other aspects of training for other residents. ANNA LAUCIS: Yeah. I would love to touch on that. So I think that COVID has been very interesting from the standpoint of just completely turning on its head everything that we thought was important about, I think, medicine, our experience. Even the didactic structure, that was one of the early changes that all of our didactics became virtual. In a sense, that took away some pressure, where we rotate between multiple sites in our training program. And that was actually one of the stressors before COVID was having to drive physically from one site to another or even in our research block and having it-- for me, I live 20 miles from my work. So having to drive that far a distance-- so that was a silver lining of having a little more flexibility there. On the other hand, I think that one of the challenges it's brought up, particularly in the context of burnout, is that I think one of the aspects of wellness and a culture of support is truly those person-to-person interactions, especially amongst trainees. That is more of a sense that we're all in this together. And especially, if we're all in the same work room, we can bounce ideas off each other or really help provide at-the-elbow-support, especially for the junior residents. That's so important. And definitely an aspect of that, I think, was challenging. Even like happy hours-- we would do a lot of those before COVID in person and just as a way to relax, relieve stress, but also connect as not just coworkers and colleagues but friends. And really, I think those friendships then lead themselves to being able to support each other better at work as well. And so I'd say that's one of the challenges has been finding ways to still connect in different ways than in person or doing virtual happy hours, so it's not quite the same. Then I'd say the other element of this-- and I've really seen this firsthand in terms of taking care of my patients. So one of the first things that happened was visitors were no longer allowed to accompany patients. And many of our cancer patients are elderly or have deficits, and they often really rely on those family members not just for physical support but also to take notes or to help them keep track of appointment details. And so even if we teleconference those family members in, it's not quite the same support as they would have by having their family member there in the room, especially for emotional times or if the patient's bringing up very difficult things. Even if we can offer a tissue or give some space for emotion, it's not quite the same as just holding the hand of their family member or something like that. And then I'd say the other aspect-- just a brief personal story I have is that a difficult experience I had recently was I helped a patient get through a very difficult treatment, seven weeks of daily radiation treatments, and talked to that patient or his family member pretty much every day of those treatments. He was having a lot of symptoms. And then it was so unfortunate that I saw about a month later that he had actually passed away from COVID and complications of COVID. And just to have, I think, put all that-- because I think, especially, this idea of defining your worth and your purpose from the outcomes of patients, that was really a crushing moment for me, I think, that I was like, wow, we got him through all of this treatment, and then for COVID to-- just this existential anger at COVID. DANIEL RICHARDSON: Yeah. ANNA LAUCIS: Why did that happen? But I think on the positive side, I guess, getting back to silver linings was that I had actually thought to call that patient's wife and offer my condolences and to see if she'd be interested in a bereavement counseling because I knew we offer that service, and I was actually the first person to reach out to her to offer that. And so I felt that even though it wasn't as much closer as I would have liked, at least I was able to offer something. And I think that's what can help lead us forward in those moments of still being able to offer ourselves to support and to provide. Even though we can't of course give her husband back, at least give what we can. DANIEL RICHARDSON: Yeah. So obviously, as we're talking about burnout, thanks for sharing that that was a crushing time, and that's OK. I think that sometimes the loss of our patients is crushing and can feel crushing, and it's emotionally challenging. So thanks for sharing that. I think that you had mentioned a couple of things about the silver linings of COVID. And I think one of them is really this emerging understanding of the importance of addressing well-being. COVID has been a shockwave that's gone through our medical system, and we've seen providers really wrestle with the ongoing suffering. And so bringing this to the fore is really important. I have really benefited. So I have a young family at home, and so I benefited quite a lot from the ability to work my non-clinic days at home. And I really hope that that continues to be something that comes out of this-- so the televisit, working from home. And I'm hopeful that we continue to see well-being as a central aspect of caring for patients well and delivering really high-quality care. So obviously, burnout is a very serious issue, and as I just mentioned, we don't often talk about how challenging it can be to walk with patients through suffering. What kind of strategies do you think work well in supporting wellness and preventing or mitigating burnout? ANNA LAUCIS: I think there's a number of ways to think of this. I think that, often, personally, in efforts I've led or what I have seen, there's almost this stigma in general about mental health issues but, in particular, about wellness. I think you had mentioned your resilience earlier that I think sometimes this-- especially in medicine and I think in other industries as well, there's almost a stigma against wellness efforts because we think about it as like putting the onus on the individual to build resilience and to add one more thing to their plate or do one more wellness module. And I think actually one of the drivers of burnout is that we're already-- our plate's already overflowing with responsibilities, and actually offloading some of those might-- I think is, in general, a more successful strategy than adding things to it. But I think it's challenging to do that, right? We can't necessarily take away the important work that we're doing in oncology. And as we were talking about we're walking with patients on this journey, we're kind of absorbing their traumas. We can't really take that away, necessarily. I mean, that's essential to what we do. But I think one of the ways that we can address it-- and what I found to be successful in my own efforts here in my training program-- is just thinking about, OK, I think there's-- even though we've been in all together, I think there's really a lot of different drivers, and addressing each one individually is important. So for example, thinking about, OK, what's on our plate that's overflowing, and is there excess of those things? And I think that COVID, again, has maybe helped us think through that. OK, maybe we don't need to have in-person didactics that are stressing us out and making it difficult for us and maybe some of-- because I think, for a virtual Zoom meeting, it's a little easier to log off or put yourself on mute if you have a child or a pet that needs something or even-- yeah, and as you talked about this flexibility of working from home part of the days, even getting to doctor's appointments or dentist appointments, that's an issue that trainees certainly have as well. And so just being able to attend to your personal needs better, I think that's a way of-- it's not necessarily taking something off your plate, but it's making something a little easier to do. On the other hand, I think that really successful wellness initiatives that I've seen really addressed burnout from the grassroots rather than top down. And so I think if it's just another one of these online modules that we do that I think a lot of us click through quickly just because there's so much, I think that that's not necessarily the most successful. But if it's really maybe a group discussion or thinking about, OK, maybe, especially in oncology, one of our issues is that we don't have a good outlet, and we don't really have a good, safe space to talk about death, illness, tragedy, all of these big, big heavy themes that we're dealing with daily. And so, actually, one of the things I've been able to implement at my institution that's been very successful is adopting this national platform called Schwartz Rounds to the radiation oncology setting. And the idea of this is to give a safe space for talking about the emotional, sociodynamic, truly community and also complexities of care that it's not just the patient in front of us and their oncologic outcome, but also the difficult family dynamics that sometimes arise in patient support as well as ethical dilemmas that can arise. But I've started at my institution is something called Radiation Oncology Reflection Rounds, and that really has given us a safe space. And we did do a virtual version of that as well recently, which went well. But this idea is we all sit around and think about the emotional and interesting impacts that dealing with cancer patients has and also the ways in which we do have an outlet to talk about this. And so these sessions have often involved even leaders in our department bringing forth their emotions in a way that I think is really impactful and sets an example that this idea of it's OK to not be OK, and we don't often talk about that enough. But that has been very meaningful. And I think you, hopefully, will continue on after I leave here. And I think the national Schwartz Rounds platform as well really accomplishes that in a multidisciplinary way. DANIEL RICHARDSON: Yeah. I think a few things that are really profound is providing the opportunity to share emotions and have a safe space. I think, too often, we don't have safe spaces in medicine to say we're not doing OK. The buy-in that you got from upper-level leadership and the mentors, those that establish the culture, is really important. I really believe that, as we build a sense of community, a shared sense of purpose within our institutions, within our organizations, within the broader community of oncology, that can be a powerful mitigator against burnout as we feel like we are in it together, that we feel like we are contributing to the greater good. That's so important. I've been privileged to develop an art of oncology program at my institution with others in psychiatry and palliative care, and it's a similar idea to allow for a fellowship program to provide a place to share our stories, to reflect on some of the more challenging issues in oncology, to reflect on suffering, to reflect on communication, to go into those places that it's really hard for us to talk about. And one of the things that we've really seen come out of that is the shared sense of meaning, this deeper connection and this understanding like, oh, you're walking through that too. And it's OK to share that this is really hard, and I don't have all the answers. And, oh, man, I don't know what to do for this patient, and I'm feeling inadequate in my role as an oncologist or as in my role as a fellow. And it seems like everybody else is doing fine, and I'm not. And having the opportunity to build those connections with co-fellows and others in one's own institution is really important. I think, for me, as I went through fellowship, there were certainly this sense that I needed to let go of things that we can't control and really saying it's unsustainable for us to think that we can save every patient, and really saying my goal as an oncologist is to, yes, deliver high-quality care, but it's really important for me to care for each and every patient, to get to know them, to get to know what's most important to them, and to let go of the burden on their outcomes. I can't pick and choose which patients the chemotherapy is going to work. I can't pick and choose who's going to have the best outcomes, but I can serve and care for each patient. And by doing so and having the opportunity to walk with that for patients, I can get a deep sense of purpose and meaning in the lives really of each patient. ANNA LAUCIS: I think that brings up a few really important points, and I think one of those-- and it really resonates with me what you said about letting go of what you can't control. And I think that goes for not only patient outcomes but also just everything that comes with the work we do in medicine. It's often very busy. There's often many workflow issues that are beyond our control, or the patient showed up late, or then they're not roomed in time, or just all of these workflow things. And I'm sure on the inpatient side as well, as I saw in my intern year, certain labs taking longer than they should to come back or various things that there's just all-- it's really a lot in our profession, I think, that's outside of our control. And so I'd say that I agree that one of the ways that I've been able to really cope with these issues of burnout, the best has been-- and I think a successful strategy, in general, for these issues and challenges in life is being able to walk back from that and say, OK, set a boundary like a mental boundary. OK, what's in my control, and what's not? And I think some of these inspiring quotes that have really resonated with me are these ideas of saying, OK, what are the things I can control? I can control that I show up on time. I'm compassionate for my patients. I'm taking care of myself right-- sleeping, eating, the bare-bones essentials. And yeah, I'm going to be a supportive colleague for my co-residents. I'm going to help them out when I can. But you know what, at the same time, I'm human, and I'm going to inevitably make some mistakes. But I can't dwell on those or beat myself up about those, because you know what, I need to be able to bring my whole self to the next patient. And I think that's really been a healthy approach for me, and I've been able to really overcome a lot of barriers that way, being able to say, OK, all of these extra things that are going on, whether it's the patient's outcome or the workflow concerns. And I think humor too can be helpful, even if it's cynical humor, saying, well, of course, on a Friday, I'll get three urgent patients that I need to essentially stay overnight to treat. That happened on my last call week, but the good thing was the supervisor who was on call with me and myself, we just approached it with a smile, and yep, OK, this is Murphy's Law. I know it's going to happen this way. And I think that can truly help these, again, existential things. Well, you can't control this, but of course, that's going to happen this way. And so I'm curious as to, for you, Dr. Richardson, what other strategies you've had in personally coping with burnout in some of these issues as well. DANIEL RICHARDSON: So I think that you mentioned about coming at your patients as a whole person. And I think that that's really important. I am a huge proponent of thinking as a community of how I can find meaning and purpose in our work. But as I mentioned before, this work can't be all that we have. So I think it's critically important for us to establish patterns in our lives of rest, of quiet, of rejuvenation in order for us to come as whole people back to our patients and back to our colleagues and coworkers. For me, my Christian faith and my family are tremendous sources of strength and encouragement. And I really think that it's important that, as a community, we recognize that, as whole people, as we come to our patients, we need to encourage the others to find those places of strength and encouragement outside of medicine, even if that means, yes, we need to encourage vacations, even if that means we take call for other people so they can establish better patterns of rest, et cetera. ANNA LAUCIS: Yeah. And I would echo that as well that, really, and I think too of this idea of redefining what success means as well. And I think whether it's medical oncology, radiation oncology, surgical oncology, really, all of us are very high achievers, and we're used to not only being able to, to some degree, control the outcomes of our own successes based on the effort we put in. I think one of the true challenges of a field like oncology is that, regardless of how much effort we're putting in, how many extra hours we're putting in, that sometimes just the biology is very challenging. Some cancers-- and by now, at the end of my training here, I've learned which one is that, OK, if the pathology comes back, it's that. OK, I'm going to have to really reframe my discussion with the patient and, again, this idea of not giving them false hope. But at the same time, I think, really, there's a lot of tools from palliative care and this idea of, OK, this is a difficult situation, but we're going to fight it with everything we can, and this idea of even if we can't cure your cancer, we're going to be able to use support to help you feel as well as you can for as long as you can. And so I think that having more tools in the toolbox, I think that rather than this naive thinking of, oh, the only good outcome for a patient is cure, really, I think-- and especially in palliative care rotations I've done-- and it sounds like you've had a lot of experience in that as well-- this idea of a good death or this idea of patients really meeting their goals and what they value. And I think really digging into that, it can not only help us really give our best efforts for the patients but also their family members, and also just, again, reframe this idea of what's a good outcome. And in some cases, the patient will succumb to their disease, but if we can offer them peace, better time with family, reconciliation of difficult family dynamics, or just reduced nausea, reduced headaches, reduced fatigue, I think all of that can be considered a success. DANIEL RICHARDSON: Yeah. I think it's a great point to say that we cannot define our success by the clinical outcomes of our patients. I personally define success, and I encourage residents and others that work with me of saying, let's care for each patient. Let's deliver quality care to our patients and care for them. So that is all the time we have for today. I want to thank Dr. Laucis. This has been really great. I think, as we begin to allow COVID to bring up wellness and well-being into the forefront of our minds, I think we have a tremendous opportunity to engage each other on furthering this conversation for how we can better mitigate this in our community and develop a deeper sense of community and purpose as an oncology community. So it's been a wonderful conversation. Thanks for listening to this episode of the ASCO Education Podcast. [MUSIC PLAYING] ANNOUNCER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

In the second of ASCO Education's two-part episode, Todd Pickard, MMSc, PA-C (MD Anderson Cancer Center) continues the conversation with Drs. Daniel McFarland (Northwell Cancer Institute), Sayeh Lavasani (City of Hope), and Fay Hlubocky (University of Chicago) about individual and institutional interventions to prevent and address burnout among oncology professionals. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 6/30/2021 TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] TODD PICKARD: Hello, and welcome to the second ASCO eLearning podcast episode focused on burnout in oncology. In the previous episode, our guest speakers discussed what burnout is, its warning signs, risk factors, preventative measures, and talked about their own personal experiences with burnout. My name is Todd Pickard, and I'm an oncology physician assistant at the MD Anderson Cancer Center. I'm pleased to introduce our three guest speakers as we continue our conversation on the prevalence of burnout and its implications for personal well-being and professional satisfaction. Dr. Fay Hlubocky is a clinical health psychologist and research ethicist at the University of Chicago Medicine. She's also co-chair of the ASCO Oncology Clinician Well-being Task Force and has extensive research experience in burnout. We're also joined by Dr. Daniel McFarland, a medical oncologist and consult liaison psychiatrist specializing in head and neck thoracic malignancies and psycho-oncology at Northwell Health Lenox Hill Hospital. He has conducted research on empathy, resilience, and distress in trainees and edited an upcoming Springer book publication entitled, Depression, Burnout, and Suicide in Physicians. And finally, we are also joined by Dr. Sayeh Lavasani, a medical oncologist specializing in breast cancer and an assistant clinical professor in the department of medical oncology and therapeutic research at City of Hope. Dr. McFarland, you mentioned that you've been involved in research on burnout. So tell us, how prevalent is burnout in oncologists? And is it getting better or worse? DANIEL MCFARLAND: Thanks, Todd. Yeah, good question. The research that I did was more on empathy, resilience, and distress, not burnout. I didn't actually measure burnout. But the latter part of your question, I'll tell you that some data indicate that it is increasing. In general, oncologists are in the middle of the pack in terms of medical specialties and where they fall in terms of how burnt out they are. And it really speaks to the drivers of burnout being not always what you think that they might be. As a specialty, we see a lot of the patients at the end of life. But as has been mentioned, these are really more systemic, administrative of issues, although it can be communication. And again, it's just everyone is a little different in that regard. So whether it's actually increasing or we're just having more attention to it is probably a good question. But either way, it's there, it has been there, it's a problem, and we should do something about it. TODD PICKARD: So Dr. McFarland, I really like the fact that you just said we should do something about it, and that leads to my next question. Is there any evidence-based interventions that we can use to prevent burnout? DANIEL MCFARLAND: Absolutely. There are several good meta-analyses in fact. So people have been looking at this across the board. The caveat is that they're not always specific for the setting. And I don't think there is a way to make that necessarily possible, given the multitude of settings. But in general, across the board, doing something seems to be better than nothing. The issue is, well, are they durable responses? And what exactly are you measuring? So if you have a drop in burnout by two points, is that enough? It looks like actually even a few points-- and I think it's around four points on the Maslach scale, MBI, Maslach Burnout Index. Fay can correct me on that, I guess. But if there's just even a small drop, then that has been shown to be a meaningful change, which is wonderful. Now in sub-analyses in these meta-analyses, they've shown that the kinds of interventions that are most effective are organizational interventions. And most of those types of interventions are things like work hour restrictions and workflow modification. But the big caveat there is a lot of those were done in trainees, where they would have work hour restrictions. So again, you have to sort of take the data for what they are. And if it's applicable, then great. If it's not, maybe try something else. So the take-home message is that the organizational type interventions are not only more efficacious but seem to be longer lasting in their efficacy. But that doesn't mean that individual interventions don't work, because they do. They also work. And I would say from the sub-analyses that I've seen, if the interventions incorporate mindfulness or some part of CBT-- that's Cognitive Behavioral Therapy-- those interventions seem to work the best. The combination would be ideal of organizational changes with individual types of changes. And a lot of this comes down to sort of system-based changes. I think of adaptive trial designs, that's essentially what's needed. One thing's going to work in this setting, another thing will work in another setting. Each field has its own drivers of burnout. I'll tell you, for example, totally outside of oncology, that with psychiatrists, who, again, don't have the highest rates of burnout for probably the reasons that we talked about, but actually violence. A lot of psychiatrists have been hit by a patient or had violence thrust upon them. And it's a real cause of burnout. I just would have never exactly put that together. So the point is that for each discipline, there are specific things, and then there are general drivers of burnout. I think we all work with the electronic medical record. We all have bosses and administration that we work for. And so it's a matter of putting these things together. TODD PICKARD: Yeah, it resonates with me that there's a lot of things that we hear about, but then there's a difference between understanding what's out in the literature, what you hear articulated, but then how do you turn that into practical methods. Dr. Hlubocky, how can our listeners adopt some practical methods for preventing burnout that's easy to implement? FAY HLUBOCKY: Thank you. Awareness and education is key, truly being aware, truly being motivated. We talked about self-assessment. That was actually one of the first strategies that we described in our educational book in 2016 with Dr. Back and [INAUDIBLE] of really doing, as Dr. McFarland talked about, really doing that self-assessment. 1 to 10-- how irritable, how sad, what am I? Rating that, and not just rating yourself multiple times a day, having a barometer. And again, asking that trusted observer, maybe it's your wife, maybe it's your colleague. And then, of course, to seek support if that is needed if it does become too extreme. But clearly, we know awareness and education is key-- education. So some of the early internal medicine work showed that a simple one hour educational talk on burnout, on well-being not just informed the attendees but also compelled them to practice preventative behaviors. What was that? Exercise, getting better sleep, trying to leave work on time if they were able to, better nutrition. It is these simple things. I work with oncology fellows and teach them communication. And we have a formal burnout and compassion fatigue course. And that is what we did in one study was just do an education, a little didactic, six months later evaluated them using the protocol and the MBI. And similarly, they changed their behaviors. They changed their practices, even the qualitative responses told us. So education is so key. And I motivate leaders so much to simply have a one hour [INAUDIBLE] grand rounds on burnout. Get some CMEs, so it motivates the docs to come in and to attend and to learn, because it is only through education do we know what to look for and what to address. Self-care is critical. I cannot emphasize that enough. Yes, burnout is an occupational phenomenon, without a doubt. But in order to find meaning and joy and purpose in your work again, to find, to research, to rekindle that joy that you have, you have to practice some techniques. So again, it's these preventative behaviors, again just basic needs of sleep and nutrition and exercise, but it's also things like writing a narrative. When you had a patient case that maybe went a little bit south, write a little narrative about what happened so you can be self-reflective of that. Journaling, talking about that patient's story, that patient's story that went well, that patient's story that went really bad. Gratitude-- gratitude is kind of a newer phenomenon coming out, but we teach docs to just name three things that you're grateful for in the morning, in the afternoon, and before you go to bed. It's a way of seeking self-compassion and kindness where you haven't been. Mindfulness-- Dr. McFarland talked about mindfulness. My conflict of interest is that I am a mindful teacher. I teach this with patients and with my colleagues and students. It is intentional, purposeful. It's not about sitting in the corner and doing some yoga and breathing, but truly teaching the docs, teaching my colleagues to do some breath work before they start their EMR, right? Mindful handwashing techniques of really taking the time when we're washing our hands, a real contemplative practice to be able to recharge and refresh during that course of the day. Although self-care is critical, and I view it very much as it being your life preserver, sometimes when colleagues say it's my organization that's really beat me down, it's not my fault I'm burnout, my analogy is, gosh, if you're on a sinking ship, won't you use your life preserver? That's what self-care is. But equally important is for the organization to please provide that support, to empower the oncology clinician to use the team. So many times I encourage the colleagues to use your team members. We're all in it together, but to truly work together as a community, because it's only as a community we'll be able to address this issue in that. So truly, self-care is vital without a doubt, can't say more than enough about it. TODD PICKARD: So many things that you just said resonate so strongly with me, that sense of community where you feel like the stress and everything that you're going through is shared and that sense of gratitude. Just thinking about a few things that are going right, it just lowers the threshold. It lowers the stress. So let's stick with stress for a second. Dr. Lavasani, in your experience, what are the effective strategies that you've used or experienced to mitigate stress level that are helpful? SAYEH LAVASANI: When I experienced burnout, then I decided to learn how to cope with it and to reduce my stress level. I realized that situation was not sustainable and I needed to take some action. So what I do is that I usually set aside one hour every night for myself to do things that I enjoy. It's like my me time. So this could be cooking or reading a book one night, or watching my favorite show on TV or Netflix the other night. And also one way that I relax is by listening to music. When I'm tired of doing my administrative work or days that I'm in office, I just listen to my favorite song. It's just three to four minutes, but it makes me feel better, and then I go back to my work. It's also, I think, it's very important to set aside some time to do exercise. If it's not possible every day, but a few times per week. And our nutrition is also very important as you know. Fay was mentioning as well. Initially when I started working as an attending, I was always skipping lunch in clinic. But then I learned that actually taking that half an hour break to have lunch helps me to feel better and to recharge, and then I can go back to my clinical duties. And also, I try to stay organized and complete my tasks on time. It helps me to avoid procrastination. That really increases my anxiety level, because then I feel like I have unfinished things to do and just that it increases my stress. So I try to really be organized and to be on time for everything. And this is something that is very difficult-- I'm learning to do that-- And that's basically to say no to unrealistic demands. Medical oncologists, like other physicians, we have learned to say yes to all expectations. This is something that we need to work towards unlearning. The expectations and demands on us is really high. And we feel like we always must serve others and their needs, including our institution's administration. We have turned into passive individuals, that we agree to whatever that is thrown on us. Unfortunately, in a lot of practices, there is a disconnect between administration and physicians. And so it is very important to engage the administration to recognize burnout. And it can really affect productivity, and they need to come up with an action plan to help physicians to do things that will make our lives easier. And definitely getting support from other team members, from our colleagues is very important. Our peers, they play a very important role in helping us and supporting us. And we always believe you are stronger if we stick together. So definitely, this is also very important to have that support system at fort. TODD PICKARD: It's really important that when there is that disconnect between your practice, your institution, the administrators, and what the individual providers need, they've got to have a resource. And that brings me to my next question. This is where ASCO has actually something that might help. So Dr. Hlubocky, you're serving as co-chair for the ASCO Oncology Clinical Well-being Task Force. Can you walk us through the work this task force is doing? What kinds of tools and resources are being developed and offered? FAY HLUBOCKY: Oh, thank you. It's such a privilege to introduce our membership to this wonderful task force that's in our infancy, and it's an honor to serve as co-chair with Piyush Srivastava. It was a collaborative effort between both the ethics committee and the clinical practice committee to gather a group of folks that are experts, including, for example, Dr. McFarland is one of our tasks force members, where we could actually focus on the oncology clinician well-being. And how have we defined well-being is it's been adapted from the National Academy of Medicine's definition that it's this integrative concept that characterizes the quality of life that encompasses that individual's work-related activities, the personal, the health, the environmental, and the psychosocial factors as well. And our mission is to improve that quality, the safety, and the value of cancer care by enhancing oncologist's well-being and the sustainability of the practice as well. We have a five-year plan. Our task force has a five-year charter and road map. The aim is really to promote well-being across the ASCO activities, diversifying resources to promote and identify the needs through research activities, to identify the needs of that individual clinician to improve the practice as well. So ultimately, our vision is across ASCO to create programs and strategies that can really help the clinician, as well as I think the cancer organization as well. As I said, many leaders come to us wanting to implement interventions and not really knowing how to. So although we are in our infancy, we have been quite busy and we have developed a research page that all members can access that has empirical research on there and also some tools that could be used, multiple resources on there. We also had a webinar to introduce the task force to the members-- of course the purposes and the charter. We also recently published an editorial in the JCO JOP talking about the impact of COVID on burnout, moral distress, and the emotional well-being of the oncologists. And that actually has multiple useful interventions that the organization might consider as well. And we just conducted a focus group study that is currently under peer review of the oncologist experience, both the personal and occupational experiences during the COVID pandemic, what is that oncologist going through. So very busy. Again, in our infancy, we have lots of plans to hope and look forward to all of these endeavors, and of course, your feedback on it. We are here to help and serve you, and we are very grateful to ASCO leadership for giving us this opportunity to advocate for the oncology team. DANIEL MCFARLAND: Can I just say one other thought that I had? When we were talking about the interventions, I was just going to say that one way that I think about the interventions that might be helpful is that there are some interventions that are sort of pulling the clinician away from the work environment, whereas others are having the clinician kind of engage more strongly with the work environment or in a different way. And the latter seemed, obviously, to be a little bit more effective or makes sense, because we've all had that feeling of being on vacation and you go back and it's the same thing. And so I just wanted to add that that's just another way of looking at the interventions. I always talk about this study that was done in Oregon like 20 years ago, because it was so genius that what they did was they basically-- it's a group of five different community oncology practices. They got together and they said, OK listen, burnout's a problem. We're measuring it. You guys figure it out, and we're going to remeasure it. And the beauty of it was that it addressed what some of the problems of burnout are-- feeling like you're in control, and then kind of having that engagement part where you're engaging with whatever you're creating to mitigate the burnout. And thirdly, it brought the oncologists together. So they had to figure it out in their own way and what made sense for them. And in my mind, that's the perfect solution. And it does help bring administration and clinicians together, because ultimately, we do all care about the same thing. FAY HLUBOCKY: It's a great example of peer support, Daniel. We always talk about peer support. And I think a lot of folks say, what does that look like? Is that a group thing? And exactly that study of getting everyone together to talk about it-- how can we make change, how can we improve burnout at our organization-- is critical. That's why it really-- it can't just be leadership alone, and we need physician champions. We need lots of folks involved in the process to ultimately improve the quality of cancer care at that institution, and I think honestly nationally and globally. That's kind of what I think even our task force is about. TODD PICKARD: Oncology is a team sport. We're all in it together. [INTERPOSING VOICES] TODD PICKARD: Exactly. If we're taking the patient's care in all of our hands, well then we all have a responsibility for preventing burnout and backing each other up and talking about this and being that trusted person to be that barometer. So it's a team sport. No person stands alone. FAY HLUBOCKY: Yeah, and the oncology clinician is the most compassionate clinician, I think, out there. Truly. Of course, I have a little bit of bias there. But truly, my colleagues are the most compassionate, kindest people, people I just love being around. But it's so tough to show self-compassion isn't? We're great at giving compassion to others, to the suffering, but to self that tends to be a little bit more difficult. So that's why we have to help all one another, as you said. TODD PICKARD: Well, this has been a terrific conversation. So thank you Dr. Lavasani, thank you Dr. Hlubocky, thank you Dr. McFarland for your engagement and conversation today. That is all the time we have. But we thank all of our listeners today for listening to this episode of the ASCO e-Learning podcast. To keep up to date with the latest episodes, please click to subscribe and let us know what you think about the podcast, leave us a review, or email us at elearning@ASCO.org. Thanks so much, everybody. [MUSIC PLAYING] SPEAKER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

In this episode of the ASCO Education Podcast, moderator Todd Pickard, MMSc, PA-C (MD Anderson Cancer Center) speaks with Drs. Daniel McFarland (Northwell Cancer Institute), Sayeh Lavasani (City of Hope), and Fay Hlubocky (University of Chicago) about individual and institutional interventions to prevent and address burnout among oncology professionals. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 6/16/2021 SPEAKER 1: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. SPEAKER 2: This is the first of a two-part episode on burnout in oncology. Stay tuned for part two of this conversation launching June 30, 2021. TODD PICKARD: Hello, and welcome to ASCO's podcast episode focused on burnout in oncology. The prevalence of burnout among oncologists and other health care providers that care for oncology patients has been increasing in recent years, bringing along serious implications for personal well-being and professional satisfaction. My name is Todd Pickard. I'm an oncology PA at the University of Texas MD Anderson Cancer Center. I'm pleased to introduce our three guest speakers today. Dr. Fay Hlubocky is a clinical health psychologist and research ethicist at the University of Chicago Medicine. She's also co-chair of the ASCO Oncology Clinician Well-Being Task Force and has extensive research experience in burnout. We're also joined by Dr. Daniel MacFarland, a medical oncologist and consult liaison psychiatrist specializing in head and neck thoracic malignancies and psycho-oncology at Northwell Health Lenox Hill Hospital. He has conducted research on empathy, resilience, and distress in trainees, and edited an upcoming Springer book publication entitled Depression, Burnout, and Suicide in Physicians. And finally, we are also joined by Dr. Sayeh Lavasani, a medical oncologist specializing in breast cancer and an assistant clinical professor in the department of medical oncology and therapeutic research at City of Hope. Many oncologists around the world are struggling with burnout, but the topic is rarely openly discussed. We are excited to launch a discussion of causes and signs of burnout, as well as proven tools for the prevention of burnout that our listeners may apply in their own daily lives. Welcome, all. I look forward to this interesting conversation today. Dr. Lavasani, can you tell us about your personal experience with burnout during your training and professional life? And then, how has the pandemic affected your experience of burnout? SAYEH LAVASANI: Sure. First, I want to thank you for having me on this podcast. I noticed the symptoms of burnout when I was an internal medicine resident and had to do 30-hour shifts covering the ER, admissions, the internal medicine service, code blues in hospital, et cetera. It was a challenging time. I had a young child and [INAUDIBLE]. I would try to relax and meditate. And the peer support at that time was critical. All residents were very close to each other, which, I believe, can be the best strategy to overcome burnout during training. When I was going through my fellowship, things were definitely better and my calls were all home calls. And then I started to work as an attending. Initially, I was under the impression that things would be easier, but I realized that my job is still very stressful but in different ways. I'm fully responsible for my patients and treatment decisions I make for them. Patients and their families are under tremendous amount of stress. We need to provide them with support and give them the strength to help them to go through treatment. I felt multiple times that this is overwhelming for my health and well-being. I experienced burnout as a [INAUDIBLE] oncologist when I was in the process of moving to my current position, which required moving from East Coast to West Coast, moving and settling in there. Very stressful. And then, this month actually marked the one-year anniversary of the start of the COVID-19 pandemic and the subsequent restrictions and lockdowns. It was an exhausting and challenging year for everyone, especially the health care community having countless number of meetings, integrating telehealth into our practices, fear of contracting COVID and spreading it to our families. When I look back at this past year I have experienced fear, disappointment, but at the same time resilience and hope. I feel that like I learned a lot. We learned how to fight a pandemic. I personally learned to appreciate my health and time with family. I learned how to use small things during my day to cope with stress better. This has been my experience so far. TODD PICKARD: Thank you for sharing that. COVID-19 has definitely added to the stress and burnout that many of us face. So thank you. It's a very common experience for many of us. Dr. MacFarland, would you like to share your personal experience with burnout? And has your approach to preventing or dealing with burnout changed over the course of your career? And if so, what's working well for you? DANIEL MACFARLAND: Yes, thank you very much. I am delighted and honored to be here with everyone today and to share my story and our mutual interest in burnout and hopefully help some people along the way. Being that I had trained in two disciplines, medicine and psychiatry, I became very interested in burnout mostly as a result of having undergone supervision in psychiatry. And then similarly to what Dr. Lavasani was saying, seeing the intense training conditions of the residents actually, once I had become a fellow, and it made me think back to a lot of the principles that I had learned undergoing supervision in psychiatry, meeting with the psychoanalysts. At that time, I was in Chicago, go down to Michigan Avenue and have these talks all about me, what my experience was in dealing with patients and life and the things that would trigger emotion for me, et cetera. And I really felt like, I wish everyone could have that experience. And it almost made me sad or angry that people didn't and-- because once I became a fellow I saw that the residents actually were dealing with the sickest patients on the wards, talking to families, breaking bad news, and the look in their eyes. Maybe my residency was rather cushy, I don't know. It was a little bit more intense where I trained for oncology fellowship. So I had started a program of research there to look at the empathy of resilience and distress. And I think stemming from that I got interested in burnout because there are these conceptual ideas that are all overlapping. And, for me, it started from this idea of, how does the patient environment affect the clinician? And, thankfully, we're at a point where we-- you said at the beginning that we're not talking about burnout, but we are talking about burnout. We're talking about it right now. And the conversations are ongoing, are increasing, becoming more nuanced, in depth. And it's actually a really exciting time. And not that long ago this was off limits, to really explore this area. And I think it's exciting and I think there's definitely hope. In my research, and I mentioned this book that we have coming out, et cetera, when you look back these things are not new, in a sense. There's always been this underbelly of medicine. And the stoicism that was pretty much the only kind of working way to move through it, like sort of put up or shut up, frankly, which didn't work for a lot of people, and now we have an opportunity to make it better. And so it's so exciting. So in terms of answering your question, it was really at the beginning an academic interest, I suppose. On a personal level, I will tell you that many of the things that you read about with burnout I've certainly experienced in practice seeing a lot of patients, that feeling of cynicism, this isn't working, losing the motivation, this is somehow losing the meaning, which is distressing. Certainly cases of moral distress are challenging and you can bring it home. And even as a psychiatrist where you're trained not to do that, it happens. And we see things in oncology that they don't see as much in psychiatry. So how do you figure that out with the help of our palliative care colleagues, et cetera, is really important. I noticed when I started practicing, for example, and it was a very busy practice at first, that I would use humor in a way that wasn't normal for me. I'm a somewhat funny guy, I suppose, but it was a little too much. And I knew that. One day I sat down, I said, this isn't me. Nothing atrocious. It happened. I don't know. Maybe I turned someone off. I don't know. But it was this little light bulb in my head like, something is different. And I just thought, OK, of course. I mean, I'm the attending now, I'm seeing-- these are my decisions, this is weighty, heavy stuff, a lot of patients are not doing well. Many patients were doing well, which is great. But you see what I'm saying. So, wow, it happens. It happens to all of us. And, yeah, that was the biggest thing. The other thing, having different, disparate interests has been challenging. A lot of what burnout stems from are systemic issues, are personal issues. How do we interpolate ourselves into the systems in which we work? Having interests in medicine and psychiatry, that's not easy. And so I've had to step back, reflect, take some life changes here and there, which I think, for the most part, has actually been quite beneficial. So you asked, what are the things that I'm doing to help with burnout? Those are a couple. I would say the last thing, we're always told to eat well, do yoga, exercise. I do feel like I understand why we need to do that a little bit more, and that's what's helpful about learning about burnout because some of these-- you get burnt out learning about all the things you're supposed to do for burnout. But if you understand the reasons why, and we'll probably talk about the data a little bit later, it's really helpful. So, I'd say a new approach to my personal burnout prevention regimen. TODD PICKARD: I agree. I am encouraged by the fact that we're having more of these conversations. And our training is really an intense, intense time. I wish 25 years ago when I went through my training that it was encouraged to talk about burnout, because back then it was not. So you simply suffered in silence, put up, shut up, keep coming, and do what needs to be done. So I'm very encouraged and grateful that we're having this conversation. We've talked a lot about burnout, but, Dr. Hlubocky, how is burnout defined? Many people, we all think what it is, but help us. What's the definition? FAY HLUBOCKY: Oh, thank you. It's such an honor and a pleasure to be with my esteemed panelists here, and especially with all of you ASCO members to talk about your well-being. That is our priority at ASCO. So burnout actually is an empirically driven phenomenon and it's been formally defined recently by the World Health Organization as an occupationally related syndrome that results from chronic workplace stress that hasn't been successfully managed. And there are three dimensions, or three signs, that are apparent. It's a feeling of physical and emotional exhaustion, it's a feeling of cynicism and pessimism, and a decrease in professional efficacy. The clinician feels like they're not as efficient as they should be. Now this is the hard-working physician. It actually starts with several stages. The phenomenon is actually not new. It was first described by Herbert Freudenberger, a psychologist in the 1970s, who noticed his colleagues on the inpatient mental health wards going through this phenomenon, this state of exhaustion and cynicism and reduced professional fulfillment and efficacy. And it's been done, well described now in the research by industrial organizational psychologists, like Christina Maslach, and more formally driven with empirical research and instruments that have been developed. And then now in the clinical setting, in specifically oncology, we have a lot to thank Dr. Tait Shanafelt because he was probably one of the first ones to really describe it in oncology and in oncology physicians as to what-- so it certainly is not new. It's not just a bad day. It's not just being stressed out. This is a chronic, insidious process that we really have to prepare clinicians for, whether they're junior clinicians, to say this is going to happen, to be prepared for it. And I really appreciate Dr. MacFarland's talk about psychiatry and psychology. We are almost a little bit more prepared for that. I think a lot of our supervisors tell us, you better watch out, you're going to be dealing with a lot of sick patients that are undergoing a great deal of suffering. Both he and I are in psycho-oncology so we work with the cancer patient and the mental health aspect as well. So there was always this kind of supervision, making sure that you were OK. And, unfortunately, I think the COVID pandemic has afforded us an opportunity to have an open discussion, to reduce the stigma around burnout, that this is simply OK. It is right to talk about your well-being, that it is important to talk about your well-being in the long run. TODD PICKARD: That's really helpful. I'm also curious, we've also heard the term of moral distress. Dr. Hlubocky, Dr. MacFarland, how do you differentiate burnout from that concept of moral distress? How are they different? Are they interrelated? Are they completely independent? FAY HLUBOCKY: So I'll take the first stab, I guess. So actually, the research, it says that either moral distress precedes burnout or that they can co-occur. It depends on what literature you're looking at. So we're all distressed. The individual is in an environment where they know what is the moral action, the right thing to do, but because of the environmental constraints around they are unable to perform that duty. And certainly, if there is an extended period of moral distress, certainly that can lead or be correlated to burnout. And the research is very clear. There have been some initial research and hematologic malignancies we've seen that Dr. Shanafelt was a part of. So both very important. And especially you being an ethicist, it's incredibly important for us to recognize that that phenomenon can co-occur and actually even precede burnout. So as a community, we have a responsibility to recognize the ethical implications that burnout really does bring. Daniel, I'm curious as to what's your perspective. DANIEL MACFARLAND: Yeah, great. I agree completely. I generally would look at it as burnout's a broader umbrella term, and that moral distress has both moral and distress-- moral implications of certain situations. The ways in which they're similar, a lot of the moral distress, as Fay was saying, come from being in a position of where your power is undermined or your autonomy to make decisions is undermined. And obviously that is tough across the board, causes distress and even-- in terms of health inequities, you can look at how much locus of control you have, predicts your health. They go hand in hand. The other thing about the moral distress is when you're making the decisions you're less likely to be distressed about than when it's other people's decision. So a lot of this actually comes out of the nursing literature about moral distress. But at the same time, there's the idea of moral success and moral climate. And so all things moral. So it's, again-- there are a lot of ethical implications to burnout, but it's more that burnout exists, the implications of burnout leading to worse patient care, worse quality of life, and all those other bad things. But this is really about specific situations. And as it happens with, I think, ethical situations, the more that they're discussed, brought up, different perspectives are evaluated, the moral distress can recede. So the solutions are different. That's the solution for moral distress. And for burnout it's a little bit more amorphous. That may not be exactly what you would need if you were burnt out. TODD PICKARD: Yeah, that's really interesting because I can't think of anything that would add more to my sense of burnout than knowing the right thing to do and feeling disenfranchised from doing that. That would be really difficult and would really cause additional stress and anxiety. And so I can see how they're related. But, Dr. MacFarland, how do you know when burnout's starting? What are the signs? What are the symptoms? And then what happens if you don't address your burnout? DANIEL MACFARLAND: Great questions. I think we have seen burnout in other people, and it may be easier to recognize the burnout in others than it is in ourselves. It goes without saying. I would be most inclined to pay attention to those subtle, automatic thoughts, if you will, that start-- as I was describing earlier, that's really the beginning of it. And looking at variations of the sort of pattern of yourself, and-- I mean, the definition of burnout is emotional exhaustion, cynicism, depersonalization, this idea of personal accomplishment. But all of that is vague. In any given day you could have a little of this, a little of that, that kind of stuff. There is a general barometer, I suppose. And I think this is one of the challenges of working with burnout is it's not going to get to zero. Where is that level that's good enough? It's hard to say. So in terms of identifying when you're having burnout, I think even, as I mentioned, sort of tongue in cheek, but even talking to colleagues, having that conversation about it is, how do you think I'm doing? I don't know. That might be a little too much. But looking a little outside yourself, so look at your patterns, like, well, why am I showing up to work 20 minutes late every day, what's going on? Trying to take a look at something a little deeper to those behaviors. And I think it's an iterative process, in that regard. Maybe change one thing here, one thing there. And so to get-- there was a second part to your question. The first was about signs and symptoms of burnout, and the second part was-- what was it exactly, Todd? TODD PICKARD: What happens when you've got burnout and you don't do anything about it? DANIEL MACFARLAND: Oh, boy. OK. Great question. If you were to ask me the same question about depression I would tell you that the general course of depression is nine months, hauling through it for nine months, don't do any therapy, don't take any medications, you've got about a year of suffering. I don't know that that's true with burnout. I think burnout really is a relational concept between a worker and the workplace. And that's a way that it's different from depression, because symptom-wise they can look very similar. So the other thing would be all of the bad consequences of other entities that are associated with burnout, namely depression, anxiety. We're talking about issues with relationships, that these are your crucial support systems. We're talking about your job, your work, your calling in life being compromised. And as has been alluded to, these symptoms can start early in one's career, even in training. And that's why they are so important to address, because it's a time when we want to be putting our best foot forward and burnout doesn't allow for that to happen. So the consequences are myriad. It's you name it. Almost anything bad. Right? That's the short answer. TODD PICKARD: I really like, and it resonated with me, when you mentioned using a trusted individual as a barometer to check yourself. But it also seems that having that trusted person that you could even talk about it with might be a way of preventing or supporting or addressing burnout. So I really like that idea of somebody that you can trust and check in with. So, Dr. Hlubocky, how does this show up at work? What are those work-related and personal risk factors that can make us really susceptible to burnout and depression? How does our practice environment, what's its role and our risk for burnout? FAY HLUBOCKY: Yeah. Well, first I'll speak a little bit historically what research has identified as what are some of the individual and the organizational risk factors. So originally and historically a lot of research and studies have confirmed that it was the single, the unmarried, mostly female, junior clinician, the very type-A personality, very dedicated to one's job, not knowing when to set boundaries, very much dedicated to patient care, potentially the community oncologist, for example, that was the person most prone and at risk for burnout. But also, now we have identified that it affects actually everybody at every point in time in their career. So although females may present with exhaustion, males present with a great deal of cynicism. So those kind of earlier research has really changed. And the COVID pandemic, in particular, we'll have to see years from now, but the research that's in its infancy it says that the sense of loneliness, the fact that the oncologist really misses their colleagues, their patients, even the family members, that isolation that they have had to undergo as a result of caring for potentially COVID-positive patients, that is quite challenging individually. But more so, we really need to focus on the organizational risk factors. And historically it's been those, of course, long hours, working with seriously ill patients, increase in administration time, the limited autonomy and independence and lack of control over the daily responsibilities that a lot of clinicians-- and the increase in the EMR, that really takes away from that clinical encounter. Why did so many of us become clinicians? Because we loved our interactions with patients. But yet, now we're more beholden to the EMR, into the computer, and doing all this administrative work. So certainly research has shown that almost more now recently, within even the past five years, that the organization, and that environment, that culture, it's important to change. It's important. Burnout is reflective of the practice help. You won't have a burnout physician if the practice is supportive in a way. And that's not to beat up at all on administration or leadership. I work with tons of leaders that want to help their colleagues, they just don't know how to. So it's important to encourage both the individual clinician as well as for the system to change. So important to optimize our clinical environment, really to change that culture, the infrastructure, the resources, the EHR. Scribes, for example, have been used in some practices as a support and really reducing the stigma associated with burnout and any mental health issues that may arise as a result of unaddressed burnout. So many colleagues are frightened to report that they're having an issue, that they might be judged, that they have to report it to their state boards. We really, really have to come together as a community to optimize oncology care and optimize well-being for the oncology clinician. TODD PICKARD: Absolutely. This is a great tie-in to the environment of care that we work in, the systems that we work in. So I'm very curious, Dr. Lavasani, are there any burnout prevention strategies that your institution, or your practice, is using? SAYEH LAVASANI: Yes. We have a well-being committee at my practice that meets once a month. We have access to an external psychiatrist, counselor, and also an internal psychiatrist. She also sits on the well-being committee. All physicians that are multiple activities that we can attend to like [INAUDIBLE] parties. And there's also Zumba and yoga classes over Zoom that, twice a week, that we can participate. And there are also support sessions using mindfulness to recognize, reduce stress. And we have also annual medical staff survey about burnout and stress. TODD PICKARD: It's great to hear that your practice and institution is taking some steps to support their providers. That's great. Well this has been a terrific conversation. I really enjoyed it. I feel that I've learned a lot from all of you. So thank you, Dr. Lavasani. Thank you, Dr. Hlubocky. Thank you, Dr. MacFarland, for your engagement and conversation today. Unfortunately, that is all the time we have, but we thank all of our listeners today for listening to this episode of the ASCO eLearning podcast. To keep up to date with the latest episodes, please click to subscribe and let us know what you think about the podcast. Leave us a review or email us at elearning@ASCO.org. Thanks so much everybody. SPEAKER 1: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive eLearning center at elearning.asco.org.

In this episode of the ASCO Education Podcast, moderator Dr. Annie Im speaks with fellows and training program directors about oncology training during the COVID-19 pandemic. Featuring Drs. Kathryn Bollin (director), Farah Nasraty (fellow), Jonathan Berry (fellow), Nino Balanchivadze (fellow), and Nishin Bhadkamkar (director). Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 5/26/2021 TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. ANNIE IM: Hello, and welcome to ASCO's podcast episode focused on the impact of the COVID-19 pandemic on oncology fellows and training programs. My name is Dr. Annie Im. And I'm an associate professor of medicine and the Fellowship Program Director at the University of Pittsburgh. I am pleased to be joined by our five guest speakers today. NINA BALANCHIVADZE: Hello my name is Nina Balanchivadze. I'm a second year fellow at Henry Ford Hospital in Detroit, Michigan. JONATHAN BERRY: Hi, my name is Jonathan Berry. I'm a first year fellow at Beth Israel Deaconess in Boston, Massachusetts. NISHIN BHADKAMKAR: Hi, I'm Nishin Bhadkamkar. I'm an associate professor in the departments of general oncology and gastrointestinal medical oncology. I'm at MD Anderson Cancer Center. And I'm the Program Director of the Hematology Oncology Fellowship Program. KATHERINE BOLLIN: Hello, everyone. I'm Katherine Bollin. I'm the Associate Program Director for Hematology Oncology at Scripps MD Anderson Cancer Center in San Diego. And I'm also the Wellness Chair for the GME Division of Physician Wellness, and a medical oncologist specializing in cutaneous oncology. FARAH NASRATY: Hi, Everyone. I'm Farah Nasraty. I'm a third year hematology oncology fellow at Scripps Clinic MD Anderson in San Diego, California. ANNIE IM: Thank you. So let's get right into it. First, let me ask how are training programs adjusted at your institution during the COVID-19 pandemic? What was the impact on learning? What adjustments did your institution make? And what has worked well that you can share with the treating program community? Let's start with Dr. Bhadkamkar. NISHIN BHADKAMKAR: When the pandemic hit us, we obviously had to rapidly make changes to our clinical and educational programs. I think the first change that came about was transitioning to telemedicine for many of our outpatient visits. And obviously this had an impact on outpatient rotations for our trainees. At the same time, we also changed all of our didactic programming to the virtual format. And this also had to be done fairly quickly to meet institutional requirements. And what we found in making these changes was first and foremost on the clinical side that trainees on outpatient rotation definitely had a perception that their learning would be adversely impacted by having less in-person interactions. And so we really relied on our rotation coordinators to make sure that fellows were involved in the telemedicine platforms to talk about decision making, and to interact with the patients. Obviously, there's no way to completely recreate the interaction. But we wanted there to be the element of fellow talking to patient, than fellow talking to the attending, and then all three again coming together to talk about the treatment plan. With regard to education, we certainly found that there was a social element that is important to learning that it was more difficult to recreate on a virtual platform. However, there were certainly advantages to the virtual setting in the sense that it allowed people to connect from different campuses. It allowed some people to participate who perhaps in a live setting would be less likely to speak up. And so using chat features and other elements, we found that there was a segment of our trainees who actually were participating more than they would have in our normal format. So clearly there were advantages and disadvantages. But I think overall it was a necessary change, and one that I think trainees in the end embraced and were able to make the most of. NINA BALANCHIVADZE: We had a lot of the similar changes as described. And I would say that what worked the best was clear communication and clear messages from the program leadership. One of the important things that our program did was we had a town hall like meeting where all fellows got together with program leadership and faculty, and we discussed going forward. And we discussed what changes will be made. And fellows this way felt empowered. We had our voice, and we were part of a decision. As you all know, the pandemic brought shock. And as the pandemic unraveled, in particular, Detroit was one of the hardest hit cities. Therefore, all of these changes I would say got to us before too many places. Another thing that worked well was splitting up the fellow group in three separate groups, which allowed two week blocks. So a group of fellows did inpatient hematology and oncology related work such as consults. In the same groups, there was a fellow who covered the clinic, and saw patients that could not be seen virtually. There was another group that covered the COVID wards. That was the group that was deployed to take care of patients at the front lines. And a third group of fellows were actually at home, and participated in remote and telemedicine type visits. So the way the structure went-- two weeks of being at home doing remote didactics. Then two weeks doing hematology oncology related work. And then two weeks doing COVID related work. Therefore, after kind of going through these phases, it allowed all the fellows to kind of have a time to decompress and decongest. So I think that really worked well for our program. KATHERINE BOLLIN: So we did many of the same things that have been highlighted already and shifting didactics online, and multidisciplinary conferences. And also clinic visits became mostly telemedicine. And we were able to institute technology within the hospital wards to facilitate interactions that may not have been in person being a consultative service as well. So those things went fairly smoothly at our institution where the impact of COVID initially was relatively low compared to other institutions across the country. So we were able to maintain a safe and functional environment. But what's been interesting is that, yes, we've been nimble in making this kind of transition, but now our eyes are open to the advantages of working and functioning in a virtual world. And we're looking at how we might carry this over in a post COVID way. I think that remains to be seen. But it's been wonderful having fellows at different centers coming together over a virtual format not just within our own cancer center from different satellite clinics, but also in combining with other cancer centers. And sharing didactic and multidisciplinary conferences and the like. So I think that the strain and the impact of COVID on our fellowship has been tricky and difficult in many ways. But it's open the door to really facilitating living in a virtual world in the future. ANNIE IM: We know this pandemic has affected everyone in some way. Regarding your personal life and well-being, would you like to share what was particularly challenging during this pandemic? What has been helpful through difficult times? NINA BALANCHIVADZE: I think that pandemic has been challenging on various levels, particularly in personal lives. A lot of the fellows live away from their families or extended family and have children. So the quarantine, and being at home, daycares being closed, I think affected a lot of fellows. In addition, having virtual visits, having teleconferences, is difficult if you have a toddler running around the house. And I think this also puts a whole new layer and dimension to the stress that fellow experienced during this time. And then there was the stress of am I going to get infected? Am I going to infect my children? How am I going to cope? And I believe that these were the questions that everybody had and went through. Personally, what helped me was collaborating and talking to other fellows. I created a Facebook page where I had included a lot of the fellows I knew not only from hematology oncology but as well as from other specialties. So I also took up a hobby. I started gardening and I started taking care of flowers and flowering. And trying to do things that were more family centered to try to get through this difficult time. FARAH NASRATY: I would agree with that. I think COVID of course now we're a year into it, but it brought so many challenges with it all at once. Maybe we were used to dealing with a challenging patient interaction or interpersonal interaction. But it just brought everything together. Not seeing your family, your friends. Not being able to see patients or your co-fellows. And then as we have talked about, just your own fear of getting sick and dying. Or your family member or co-worker getting sick. And so it was just a lot to take all at once. And I think anyone could kind of crack under that pressure almost. And so I kind of used that period initially as a stopping point for myself to kind of regroup, and see where I have resiliency skills or strengths. And where I could build upon that. And at Scripps, at my clinic, we had just recently gone through a resiliency course. So I kind of had those tools ready. But I also spent part of the beginning of COVID taking an online course called The Science of Well-being. It's a free course, it's offered through Yale available online at Coursera. And that was a really helpful tool for me to use then, and to continue to use now. Because I think as medical professionals we had an idea of the handwashing, and the masks, and social distancing. But I think in terms of emotional support, and in terms of our being, I think that also took a hit. And we really needed additional support there. And the course I took online and our course at Scripps, there wasn't necessarily anything you didn't already know. Just general reminders. But I think sometimes that's what we need. Right. Like excess use of social media is bad. Increased sleep is good. But it also opened my eyes to some other ideas that even through such a dark time as COVID something like keeping a gratitude journal, which for me is just like in the Notes app on my iPhone. But just little things like that. What are the small positives I could find in the day when I was going through such a hard time. And I think taking that course, taking the resiliency tools I had, and trying to actively remind myself of that, which I hadn't ever done in the past going through medicine, I think that really helped me kind of get through the day to day struggle. And I still use it today. So it's been really helpful. JONATHAN BERRY: So I actually started fellowship last summer. I'm just in my first year. And so we were already several months into the pandemic by the time we entered our hemog fellowship. And I think the most important kind of support in my personal life was really our program thinking about how we as first year fellows can support, and encourage, and be there for each other. So historically, prior to our year, the first year are almost all in the clinic. And so they share what could probably be best termed a very cozy office or a large closet, which of course, did not meet social distancing rules under the normal kind of new standards. And so there is was great advocacy to get us a different office where we could all be at the same workspace appropriately kind of spread out. But be able to support each other as we go through the challenges of starting this new year, and all of the ups and downs of hemog fellowship. And so that was absolutely huge was having that support at work. And on the same way, having my partner and having my close friends that we only saw each other for the first few months. I think just having those people around who are able to remind you of the world outside of medicine whenever things are really challenging was by far the most important part. And the ways in which we couldn't have those interactions that we would have normally had with far more people were some of the hardest parts. ANNIE IM: Next, I want to ask, how have you coped with remote instruction and limited in-person interaction with peers, patients, and mentors? Any lessons learned from this experience that you'd like to share with others? JONATHAN BERRY: So I think one of our big concerns as I was a new fellow in hemog was with the total change of everything moving to online education, and having less in-person interaction locally and at conferences-- national conferences, which obviously also were happening online-- there is this worry of how this would affect our learning in this pivotal first year. And I think that's something that's continued to be a question. And to be honest, I think I still have some areas where I feel like I might have learned this a lot better if I was able to sit with colleagues around a table, and talk about it in person as opposed to online. But that being said, I think there's definitely been some developments. Some things that I've learned and some things that our program has learned about how to make remote instruction as effective as it can be. I think any time we can get people talking and interacting-- like was mentioned earlier, whenever there is educational sessions that are structured in such a way that they're not just one way conversations, but they're kind of small group conversations, or they have interactive elements, or use breakout rooms effectively, those things are extremely helpful at making remote instruction stick a lot better. I think the other aspect is there are types of conferences and types of lectures that actually seem to work a lot better online. So I found that things like grand rounds and having these speakers who often I would be intimidated to approach in person to ask a question, having them online and being able to pose a question in a chat format is significantly less intimidating. And then we also have the ability of bringing in anyone at any time for grand rounds. You don't have to deal with thinking about travel, and housing, and hotels, and things like that. And so I think some of those sorts of things like invited speakers, the online format of instruction has actually worked a lot better. And I anticipate that some of that might actually stick around. Although hopefully, we will still travel from time to time and see each other at conferences and in each other's institutions as well. NISHIN BHADKAMKAR: I think that each fellowship class experienced the pandemic in a different way. And I think that it was very important for program leaders to think carefully about that the first year fellows who started last July didn't know when they applied they didn't know that they were going to be in the midst of a pandemic. And so there was a different type of experience that they had being apart from their families sometimes unexpectedly compared to other fellowship classes. And we found that it was important to try to maintain social connections within the classes and also among the three classes as much as we could. With regard to virtual instruction, the engagement and interactivity piece became even more critical. When you have in-person instruction, there's a natural flow and the natural dynamic to the learning that I think is conducive to fellows education. And when that piece was lost, it was important that we try to include as many interactive elements using small group sessions, using multidisciplinary sessions, to try to engage fellows in virtual platforms. NINA BALANCHIVADZE: I believe that a pandemic did change our outlook on medicine. And general medicine as well as on our subspecialty training. A lot of us felt lost because some of the procedures were not being done. There was a feeling of, am I going to get enough instruction? Am I going to see enough procedures? And on the flip side, we've all felt that we have had acquired additional points in our training that was important for the future, such as triaging patients better. Which before pandemic, I would have never thought that a patient with cancer on cytotoxic chemotherapy can be seen virtually. And now we had to triage which patients were safe to be seen via televisit, and which patients had to come in. We also honed on our skills on some of the basic general internal medicine issues. And I also think that having this experience and going through deployment opened our eyes to what is it like to be in the shoes of other specialists, such as hospitalists, and emergency room physicians, the infectious disease physician. So I think this period was important for team building. And it was important to further our respect for different subspecialists. So carrying that forward, I think, will be very important for me as a physician and as a specialist. ANNIE IM: What has been the impact of the pandemic on your clinical training? FARAH NASRATY: At my institution, we were relatively spared or fortunate in that they really didn't need a lot of us to come to the inpatient medicine and ICU services, which is different from some of the other colleagues on the call. But I think our biggest change, of course, was the move to telemedicine. I think we're all pretty adept with the internet and computer visits. And that wasn't really the challenge-- the visit itself. I think for me and my co-fellows, it was the loss of the interaction with our attendings that I think was tough. Of course, the educational aspect changed a bit. You were looking up things by yourself. And reading articles by yourself versus doing that with your attending. But I think there's also the loss of that kind of casual back and forth with your attending about your interests, your career goals, maybe mentorship. And just those little pieces that you didn't really have necessarily when you weren't together in the office. Or the same conversations that were lost somewhat with your co-fellows. But I think just as we've all had to do with everything else related to COVID, we adapted to the online situation also. And Dr. Bollin, Dr. Costantini, our program directors, they really made a point to have us carve out some time with our attendings to chat about our patients via email. Or to just call each other on the phone or text each other just to check in and talk. Kind of what we had done in the office. And it was kind of in a different format. But I think we were able to gain back that human interaction that we were all missing, and that we were all craving. So we really made an adjustment to using telemedicine, and to have it kind of be a positive for us at this point. NINA BALANCHIVADZE: In addition, I think, as a first year fellow I was already struggling delivering bad news in person. And now I had to do that in a telemedicine setting was particularly challenging for me. And not having a senior attending physician right there with me made things even more challenging. So I think we all had to navigate. We all had to lean on our attending physicians on some advice. And learn from experiences. And there were days where I would worry as I delivered bad news over the telephone who was with the patient, and how they were going to react with this news. And did they have the support system to take the news? So I think there was a lot of provider angst, and that really added a whole new dimension to the pandemic. ANNIE IM: Doctors Bollin and Nasraty, your institution offers resiliency training. How does has that benefited trainees at your institution? KATHERINE BOLLIN: So the genesis of our implementing the ASCO resiliency course actually came about after I attended the last in-person ASCO Annual Meeting in 2019. Along with experiencing all the wonderful things that we all experienced when we attend that conference with meeting with colleagues from around the globe to learning cutting edge data, et cetera, I also became acutely aware of a phenomenon that before I wasn't really alerted to, which was several of my colleagues were experiencing some pretty interesting signals or signs of burnout. So I became aware of these signals through some different interactions while I was there I came home. Wrote an essay about it. And spoke about this phenomenon with my program director for the fellowship, Dr. Costantini. And she had actually become aware of the resiliency course as a pilot program. So I looked into that. Did some research. Spoke to folks and fellows that had participated in the pilot. And wondered if it was something that we could use at our institution as a proactive means to help people recognize signs of burnout, and address them during their early career and training phase. So that's what we did. I brought in Dr. Nasraty and another one of our fellows to review the outline of the course, which addresses about eight different topics over eight weeks. And we tweaked it a little bit to their liking in ways that we felt could really address topics at hand that we see daily in the clinic. And then we brought in someone from outside of our institution who's a social worker that specializes in relationships. And ended up being a perfect match for leading this course with our fellows. So we implemented this program actually before COVID. And we did pre-surveys, post-surveys, and then we've run the course now another couple of times since COVID. And have been able to look back over time, and see the response among fellows that have repeated the course and those that have been taking it for the first time. And so far, the data is showing us that one of the key takeaways from the course, is that people are much more aware now of the notion of self care and wellness, and the different tools that we can use to help us develop resiliency skills. And now all of us are acutely aware of the physician burnout pandemic since the COVID pandemic. This is something that I think as a tool for physicians in training has great value. And I'll let Dr. Nasraty speak to the specifics on what she and some of the other fellows have gleaned from this course. FARAH NASRATY: So I have a couple different points. I'll start with the first one, I guess. I love our resiliency course. I've taken it a couple times since it started. And I think it's just such a special opportunity that we have. And I would encourage everyone, if they could have that opportunity, to develop their own unique to their program. But one of the things I'd mention is that our instructor had handed out a sheet on the foundations of mindfulness. Just basic concepts. But I've actually since COVID and until this point today, I keep it in my desk within arm's reach. And so when I'm having a tough time, I always refer to that and just look through the sheet. And I think about what she's told me during our course. And a lot of other fellows do that too. We kind of text back and forth about it. So it's not a cure all to have these type of courses. It doesn't take away all stresses that you have in the clinic and at home. But it just creates almost a safety net that now you know what tools you have. And where you can get extra support. And when I think about how it's benefited us as a group, I think from the fellow standpoint, the course really opened my eyes and our eyes to seeing that our peers experience the same struggles that we do. And I think that sounds pretty simple. But I think it's actually a really important point because I think in medicine everyone feels a sense that they always have to be the best version of themselves. And I know I feel that way. And even during COVID felt that way. And I think that's pretty unrealistic to always want to be the person who doesn't make any mistakes, and who doesn't second guess their clinical decisions. And this course kind of opened my eyes to that. That working through the course, we kind of realize as a group that we might need to temper our expectations a bit. And that we need to allow ourselves some grace, especially during COVID. But even after that. And that we need to remind each other and uplift each other that we're doing a good job, and doing good by our patients. And I think we all experience challenges at work and at home during COVID. And in that protected space in our course, we could really discuss these concerns openly with each other, and provide honest feedback to each other. And I think we helped to support and encourage each other. And I've personally left the course feeling inspired to continue to work on myself, and to continue to uplift my colleagues which I think is just as important. So it's been really beneficial to me. ANNIE IM: Finally, I want to ask an important question as we move forward. Do you anticipate that any of the changes implemented to oncology fellowship training during the pandemic will continue in the post-pandemic era? JONATHAN BERRY: So we've talked about telemedicine a good amount here. And I think that that is certainly something that is here to stay. I think thinking of telemedicine as an option for our patients just gives us such a wealth of opportunities to really provide patient centered care. I think as trainees and as oncology fellows it'll be imperative to learn how, as others have discussed, to triage patients and figure out who's appropriate for telemedicine and who's not. But when you consider that so many cancer centers are in major urban centers, and patients may come from hours away to come see us, figuring out when we can spare them a long drive particularly if they may be nearing the end of their life or on hospice care and yet still be able to check in on them and provide the care we need to provide from a distance, I think is just such a wonderful and crucial tool. And so while we look forward to welcoming more and more of our patients back into our clinics again, seeing them in person, giving them hugs, celebrating the wins, I think we'll also continue to connect with them over the phone and over the computer for years to come. NINA BALANCHIVADZE: In addition to incorporating some of the telemedicine visits in our everyday practice. I think teleconferences could stay, and would be welcome. I found myself attending more tumor boards, multidisciplinary tumor boards, because as I'm driving into work I'm able to listen in. And I find that there are a lot more conferences that I can actually attend virtually that I couldn't go to in person. Also, just echoing back to some of the resilience training, and of the things that we do now to learn about caring about ourselves as physicians. And our program, we are developing a position. And we are going to have a fellow who will be the Wellness Director. So therefore, this fellow will be in charge of trying to help create some opportunities for fellows, and get togethers, and some social events for collaboration as well as promote wellness for all the fellows. FARAH NASRATY: I just have one really short point to kind of reiterate what Jonathan said. But I would say that I don't anticipate telehealth to be my future practice every day all day. But I actually did enjoy somewhat getting to see patients in their home environments where they're comfortable. And there's something about them being with their dog, or their family, with their blanket, and kind of in their comfort space. Because they're always coming into our clinic into our sterile environment. And it's never as comfortable as being at home. And I like that part, and kind of learning a little bit about our patients just beyond what we're talking to them about in the clinic. So I do hope that stays around. And especially, as Jonathan said, for our patients that are coming from hours away to give them this opportunity to have better access to health care I also think is really important. So I hope that sticks. KATHERINE BOLLIN: Sure. One comment I was going to make. I think stemming from what we've experienced as physicians and training programs during the pandemic will be truly a lot more attention on physician well-being. So we think there will be a setting where we can implement resiliency courses across the board at institutions or similar kinds of programs to emphasize-- to put attention onto this need. NISHIN BHADKAMKAR: I'm certainly hoping that we are able to maintain some of the initiatives and the lessons that we learned over the last year. I think as others have mentioned, I think the pandemic really forced us to think carefully about the incremental value of in-person interaction. Whether it's in the clinic or in educational activities. And I think we've learned that, yes, there is value with in-person interactions. But perhaps in some situations we overestimate what that value is. And we underestimate what the virtual platform allows us to do. So in terms of conferences for example. As we've all turned to remote conferences, it's hard to say that the educational value of the conference has been diminished. I would say that there's a social element and a networking element to conferences that certainly can't be reproduced virtually. But I think that the ASCO Annual Meeting and the subspecialty meetings are a great example of how we've been able to maintain that educational component for trainees, faculty, and others in the midst of restrictions on in-person activity. ANNIE IM: That's all the time we have for today. I want to thank you all so much for joining us. It will be really important for our community moving forward to continue to share our best practices as we move into this post-pandemic training era. I want to thank all of our wonderful guest speakers for sharing your experiences with us today, and for participating in this episode of the ASCO Education Podcast. SPEAKER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive E-learning Center at elearning.asco.org.

Can you hear me now? In this episode of the ASCO Education Podcast, host Rami Manochakian (Medical Oncologist, Mayo Clinic Florida) discusses Telemedicine with medical oncologists Ana Maria Lopez (Sidney Kimmel Cancer Center), Estelamari Rodriguez (University of Miami) and Douglas Flora (Executive Medical Director or Oncology at Saint Elizabeth Healthcare). Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 5/20/2021 TRANSCRIPT [MUSIC PLAYING] ANNOUNCER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] RAMI MANOCHAKIAN: Hello, and welcome to the ASCO Education Podcast. Today, we will be discussing the challenges and benefits of telemedicine in oncology, something that has become especially important over the last year in the wake of COVID-19 pandemic. My name is Dr. Rami Manochakian. I'm a thoracic medical oncologist and a vice chair for education at the heme/onc division at the Mayo Clinic, Florida. As the host of today's podcast, I am very excited to be joined by our three distinguished guest speakers. And I'll let them introduce themselves. ANA MARIA LOPEZ: Hi, my name is Dr. Ana Maria Lopez, and I'm a medical oncologist and an integrative oncologist. And I am professor and vice chair of medical oncology and chief of the New Jersey Division of Cancer Services at the Sydney Kimmel Cancer Center in Philadelphia, Pennsylvania. RAMI MANOCHAKIAN: Welcome. ESTELAMARI RODRIGUEZ: Hi, I'm Dr. Estelamari Rodriguez. I am an associate director of community outreach and co-lead of the Thoracic Sciences Group at the Sylvester Comprehensive Cancer Center at the University of Miami. DOUG FLORA: Hi. I'm Doug Flora. I'm a treating medical oncologist. I'm also the executive medical director for oncology here at Saint Elizabeth Health Care just out of Cincinnati, Ohio. RAMI MANOCHAKIAN: Great to have you all here. Without further ado, we'll go ahead and start with our first questions. We all agree, this has been a very, very hot topic lately. And it's probably, for quite some time, it's going to continue to be. When we talk about telemedicine, specifically in oncology, what are some of the main advantages of telemedicine and oncology for patients and for providers, respectively? DOUG FLORA: So obviously, this year, we dealt with a lot being handed at us. And I'm glad that we're coming from three different sections of the country because I think our perspectives will be unique. I'm coming from a community aspect here. We have about four or five hospitals in our system. And I practice in a place that's partially Cincinnati-based, and partially some patients from deep and rural Appalachia. And so obviously, there's some access issues that I think we'll talk about a little bit later. I will say, in our system, it was interesting. We've been trying desperately to get our doctors to embrace telehealth before coronavirus landed on our shores. And it was a struggle as you guys know, and I think we'll talk about. There were some reimbursement issues, and the way that we approached this as a system was not finding traction with the providers. So we went from about 250 patients on virtual visits or telehealth visits the year prior to COVID, to almost 250,000 in our large physician group the year after. And so I wondered if you guys had a similar experience where you were sort of pushed off that burning platform and all of a sudden, had to adapt to technologies that were maybe used in regular world but not yet in medical world yet. So how are things in Miami, Dr. Rodriguez? ESTELAMARI RODRIGUEZ: So at the beginning of the pandemic, as a system, we turned all our visits from in-person to, overnight, telemedicine. And we had a system where you could connect in our electronic medical record via Zoom. But our patients didn't have that system. So there was a large kind of growing pain in terms of getting the patients adapted to the technology. And still, a year later, patients have a tough time with the technology. But I think one of the great advantages of telemedicine, and we have learned, is that it really brings the medical visit to the patient in a different way that we were not doing before, so that I can share with you, we had patients during the pandemic where our doors where close to families and we were able to continue communications with patients and their families. I had one visit where the children joined conversations from, like, Los Angeles, New York, and Miami. We were all in the same virtual world really talking to the patient about a new diagnosis of lung cancer. And that was, I think, where it was a different-- it was a discussion that we couldn't have had for many reasons, because it would have required travel. It would have required a lot of expense from the children having to take time off work. And I think our patients, especially in the community, really embraced the idea of being able to be at the doctor's office without having to take time off. We know that it's a lot of financial toxicity to our treatments and driving into the city to get into the cancer center. So that's one thing that I think telemedicine will be here and continue because patients wanted that. They wanted that access to the patients when they needed. And they wanted to have more family members in the visit. And then, one thing that we also have done, we have some diagnosis that we have to coordinate care with different specialists. So we started a multidisciplinary clinic in thoracic oncology during this time. And in one disease that it has really helped us has been in mesothelioma. So these are very rare cases that require complex surgeries from rehab doctors, pain management, thoracic surgeons. Sometimes, we need surgical oncologists for the abdomen. So that's a lot of medical visits. And we've been able to have all of those visits at once for the patient. So I think, really, it's allowed us to provide care for patients in an expedited way, in a more kind of effective cost-saving way for the patients. And also, to have these conversations between specialists in the same virtual space with the patient makes the patient feel like they're at the center of this discussion. And it's more transparent. So I think that we have learned that telemedicine can be used for really, making care more comprehensive. And I think we have more challenges. And Dr. Lopez, I wanted to hear about your practice, how you have integrated telemedicine and the challenges of trauma medicine. ANA MARIA LOPEZ: Thanks. Thanks. The multi-D clinics sounds fabulous that you've been doing. You know, one of the things, of course, for all of us, has been that telemedicine has allowed people to stay safe, clinicians to be safe, patients to be safe, families to be safe. And I think of myself as an old-time doc because one of the things that I really love about it is because it's brought back the house call. So we get to be at the bedside with our patients, be where they are. Some people call it getting back to the website, which I think is a great term. But really, we're where the patients are. We learn so much more by seeing them in their home environment. And also, seeing who's living with them, who's close with them in a much more intimate way. So I think those are factors that are really tremendous advantages from the perspective of helping to take care of people. RAMI MANOCHAKIAN: Yeah, I love all these ideas and thoughts. I mean, we clearly all have felt it was maybe hard at the beginning. And I know we'll talk about this throughout, but then, it came with a lot of advantages. And I would add, probably, a couple of things as well. I think patients, when they are being considered for clinical trials or being referred to another center, or for a second opinion, of course, we know we're missing the medical exam part. We're missing certain things. But sometimes, we ended up saving many patients that trip, and get them into the multi-D clinic after knowing exactly what we want. Certain things that we used to do by reviewing the chart and maybe on the phone, and now we have an official introductory visit save them. The other thing where it helped me a lot, and I'm a thoracic oncologist, is after the first visit when I sent a bunch of testing, genomic testing scans and others, and I want to schedule a follow-up to go over the results and set a treatment plan and the patient lives a few hours away, and we want to make the next visit maybe the treatment visit. So this is where, actually, it helped a lot. So we set this video visit, reviewed all the results, set a treatment plan, discussed. And every patient essentially loved it. So I'm glad we all share the same feelings. Speaking of which, of course, any new things come up. I don't know if we could call it new things, but when telemedicine kicked in, as Dr. Flora mentioned, at the beginning, everyone was nervous. And once it started rolling, even though it rolled very smoothly nationwide, but it still came up and will continue to come with some challenges, some drawbacks, maybe some limitation, whether it is a technology, infrastructure, communication. So I would love to hear your thoughts about what kind of challenges you've experienced or you continue to experience, or maybe you think may happen down the road with telemedicine and oncology. ESTELAMARI RODRIGUEZ: So I will share with you, in our community, we have a very large Hispanic population of different educational backgrounds. So I think one thing that became very clear to us is that we do have a digital divide in this country. And all our patients can't adapt to this technology. And a lot of the technology was not developed for telemedicine, was not developed for older patients that have difficulty in hearing, that may need interpreters. So there's a lot of things that were not thought out because we didn't know we would be in this position. But I hope that the technology will evolve to be more user-friendly. We try to kind of make it work. So we had a system that is HIPAA compliant, we assume. But there were patients that we would have to connect with them by WhatsApp out of emergency, which is something that a lot of our older patients are used to using with their families in South America and to stay in contact with family members. So we tried to adopt what they knew, what they were comfortable with, with what we had. But ultimately, we hope that we come out of this with a better system that can reach different patients that have different needs. So, Dr. Lopez, I wanted to hear from you, from your experience in your community, how you've been able to reach this digital divide. ANA MARIA LOPEZ: Yeah, I think that's such a great point. And certainly, the whole COVID/telemedicine experience has exposed so many gaps in where telemedicine, which is intended to increase access, really, there are clear barriers. And that's one of them. So there are folks, as you were saying, with WhatsApp or even just with audio, that we've been able to manage, and whether it's elders. And we really need more research in those areas to see what are the areas where this could be effective, and what does sustainability look like when there's this variability in digital knowledge and digital access? Are there ways to get technology to people? So we were fortunate in that we were able to get technology to patients. But having technology and being able to use the technology is not the exact same thing. So really, having to ask, as part of our clinical history, do you have stable internet? If you have stable internet, do you have a device? If you have a device, can you access the portal? And if you can access the portal, can you access a telemedicine visit? And only after all of those questions, to then be able to say, OK, let's do a test visit and see how that works. So we really had to change our thinking a little bit. And then, some of the comments that have been made around the physical exam and. Dr. Flora, I'm sure that that's something that you've experienced. And maybe, what's your sense of the limitations of assessing people at a distance? DOUG FLORA: I love the webside visit. And it really is a house call for us. I would say that initially, the barriers were steep. We would log on, and you're used to an every 20 or 30 minute schedule in my office. And you'd spend 15 minutes trying to figure out how to turn their mics on. And as you guys have suggested, this digital divide is still pretty deep where we live and practice. The majority of our cancer patients are over 60 or over 65. A lot of the ones that we're taking care of live in rural areas that may not have access to broadband or good cellphone access, or at least shoddy cell phone access on occasion. And computers are largely non-existent in a lot of my older patient population. So we've had to meet them where they live. I would say also, we're dealing with a lot of social determinants of health and health literacy. And while there might be an advantage reaching some of these rural populations, on the other receiving end, they've got to have the technology and the ability to log on to talk to us. So like Dr. Rodriguez, we did pivot a little bit from our beautiful HIPAA compliant, EPPA built-in software to FaceTime or just telephone calls. And it was what we had at the time. And I think everyone adapted as we needed to. But as we move forward to sustain this, I think you're correct exactly, that we need to look at the research to understand that when we adopt this permanently, which seems like it's going to be the case, that it's with methods that improve patient care outcomes, and that we're careful to abandon elements that harm patients or widen these disparities that we've just identified. RAMI MANOCHAKIAN: Great points, I think, by all of you. The one thing I would add also and I know was brought up, is there are certain times or certain scenarios where maybe from a communication standpoint, that I felt maybe a video visit, telehealth visit wasn't ideal, especially with breaking bad news or sharing scans. Fortunately, most of the time, when there is a scan, right, we order a lot of scans to assess response. And the patients are here anyway. So these happened to have it be as an in-person visit. I've had patients where their scan was a few days before, so ended up the result was a telehealth visit. And I felt that probably, even though there was an eye contact, I could argue. I had a fellow with me who said, well, the patient was surrounded by multiple family members at home. So even though we breaked not a good news, per se, they were able to take it. But I still felt it was a little awkward moment. And I would say, usually, like a major visit, scan assessment, change in treatment plan, I would prefer for them to be in-person. But to your point, maybe we need some research, more understanding, as it could go either way depending on what patients favor. But great. I think we can move on to another question. ESTELAMARI RODRIGUEZ: I was actually going to add something. So one thing that I have realized and I have kind of told my patients is that this is still a visit to the doctor's office. So I have seen that over time, people have very busy lives and they think they can do the telemedicine consultations while they're driving or they're watching TV. So there's a lot of distractions. And to your point, some of these discussions that we have with patients require preparation. You don't know who's in the room with the patient. Maybe these are news that they don't want to share with the whole group. So I try to make it very serious to our patients and our nurses ahead of time, get information from them to tell them, your doctor will be coming to the room, the virtual room. And this is a visit. You can't be in the car. I mean, these are really serious conversations. So I think we have all seen that telemedicine can be used in different settings when people are busy. RAMI MANOCHAKIAN: Yeah, Great point, absolutely. Absolutely. And one quick thing I would add also, I think it was brought up that video and audio, to me, when it's an only audio, that's almost like a phone call that we all do all the time, supporting our patient and calling them. So we've had patients that the video didn't work out so we switched it to audio. But for me, I'm always trying to avoid just an audio visit on the phone. I know now the new system would let you make it as an actual visit and bill for it. But I think to me, the real telehealth is an audio/video, actually seeing the patient face, some eye contact. I would consider a lack of video in some instances is a major barrier. But hopefully, we're kind of overcoming that. ANA MARIA LOPEZ: But again, really, such an opportunity for research. You know, let's answer the question prospectively. And at least, to me, something that was always so shocking was that telepsychiatry is so well-documented. And some of that is in audio only. So I think the questions are wonderful because it's really allowed us to raise the questions. And now we can really think, how do we answer these questions? RAMI MANOCHAKIAN: I think this would be a very good segue to our third question. From your experience, what are some of the best practices for conducting, I guess, a well-designed or productive telemedicine visit with the patients? What are the keys for a good successful visit in your opinion? And I'll start with you, Dr. Flora. DOUG FLORA: This is another adjustment for us, wasn't it, guys? I can't tell you the number of patients who don't know where the lens is on their computer or on their camera. And people are looking all over the place. And I found that maybe taking a moment to reintroduce the concept of the visit. Can you see and hear me OK? Because not all the time is the audio getting across as clearly as I think it is. I tried to make sure that I was really looking into the camera so that there was that sense of intimacy that you'd mentioned that a doctor and a patient share when they're at the bedside together. So actually, I start my virtual visits. I did one yesterday and we start by a tech question. Are you able to see me? Are you able to hear me? Thanks for allowing me into your home. And then, I do take a moment to sort of reflect on the place that the patient is living. And this is a unique opportunity to go into their cave and see how they live. Are they disheveled? Is it messy? Are they hoarders? Is it a safe place? Does it look like somebody who's keeping up with their life? And I did think also, part of the visit that was unique for this is we see them without makeup on. We see them without earrings and lipstick and the things that you put on before you go out in public. So a lot of times, I would find them in their night clothes or their pajamas. And so the visit would proceed. We're doing a physical examination while they're talking. And you could see them showing you around their living room. And you can see their eyes moving in four directions. And I think for us, the adaptation is, is you actually can do a pretty decent physical examination if you're careful to ask the patient to participate. And we got pretty adept at it. And so now, I think most of us probably have figured out how to do things like patient's not having any retractions. There's not any obvious accessory muscle use. The breathing is non-labored. There's no grunting. It's a pretty good assessment that the lung cancer patient is OK, not as good as we'd like to see if we can use our stethoscope on the back. But it's also not as bad as it sounds when you looked at it at first glance. So what other adaptations did you guys make? ESTELAMARI RODRIGUEZ: I think Dr. Lopez mentioned something that we have done as a system, where we have, at the moment of making that appointment, we're trying to identify which are the patients that will have issues with the technology. So we make that as part of our screen. So we spend more time prepping that phone call. And I also take the point that one thing that has helped and made the patient part of the team, we have asked patients to take their own weight. And some of my patients with lung cancer, they have purchased a pulse oximeter. So they are able to give us part of their vitals. And we have learned, and they have learned, that that makes the visit more useful and get more information from them. So the patients can participate in a way that they were not before. But I think it's important to really understand what the barriers will be upfront. Because you really have a 15-minute visit, and it's not the time to learn how to get an interpreter or learn how to set up the computer. I mean, it's a lot if you want to keep the day going. RAMI MANOCHAKIAN: Yeah, I like those thoughts. It's prepping. Obviously, we're sharing all that we need to prep well and set good expectations. I have a lot of good questions that I think our audience would be interested. So I'm going to, for the interest of time, I'm going to keep moving. A probably related question, and I'll start with Dr. Lopez, considering all that we've discussed, can you tell us how telemedicine-- we've been doing it for a year at least now-- have impacted your existing relationship with patients and family, and affected building maybe future relationships with that? ANA MARIA LOPEZ: Thanks. I do think that one can create good relationships, even if it's online. And I know that was something we all had a lot of hesitancy about, especially at the outset. And certainly, some of the initial thinking around telemedicine was that this would only be for follow-up visits. And again, sort of being an old-time doc, I think I had some trepidations around that. But I really think you can. And part of it, I think, is training for us. So we've talked about the education for the patient and setting the stage what to expect, but also for us. How do you look at the camera so that the patient feels that you are engaging? Pausing, speaking more slowly, intentionally giving patients space to communicate. I think all of these are factors that we can do, and probably would help us in our in-person communication as well, but that really helps us to stay connected. I think the point that Dr. Rodriguez made of, you want to know who all is in that virtual room. So who's at home with you? Let's bring them into the conversation if the patient would like. Or, if the patient really seeks privacy, is there a way that we could have this encounter be more private? So I think all of these things that we normally kind of do to help patients be at ease, we just need to translate to the tele space. But I think that there's a lot that can be done. I think there's a lot that can be done from an educational perspective. And then, when we finally meet in person, even though we're masked and all of that, I think people can really feel connected to us. I wanted to share just very early in doing telemedicine. And this was-- I was accompanying an infectious disease colleague. And he was talking with a patient. And at the end, it was the patient's first telemedicine visit. And so at the end, you know, well, how was this for you? How different? What did you think? And at the end, all the patient said was this was great. The only thing I miss, and the patient went up and hugged the monitor. And I do think it is something that we miss. But there's a lot that we can do. RAMI MANOCHAKIAN: Absolutely. Absolutely. Great thought. And Dr. Flora, I loved when you mentioned earlier, you thanked the patient for welcoming us in their home. I think that was a great way to start things. What kind of feedback you heard, Dr. Flora, from patients? You've been doing telemedicine for a while, and as far as the relationship and their thoughts on this? DOUG FLORA: I'll tell you, I was surprised it's a delighter. We think they want to be with us because we're doctors. And who wouldn't want to come see these minds? And that's not the reality at all. And you know, I would say almost exclusively, the patients have benefited from it and have told me so. They prefer getting that hour back. Ours is a place there is a good travel burden for the majority of patients that we treat. And you know, obviously, it's very challenging. I'll say as a hematologist, sometimes, I'll check a patient's platelet count. And it literally is a 5-minute lab draw. And we can tell with really good certainty that that patient is in good shape and didn't need to make a 45-minute drive and a 30-minute wait and a 45-minute drive. So I would say they've been appreciative that we're now able to care for them in a compassionate fashion that's thorough and that answers the questions that they have. And if we're fortunate enough that that patient's care didn't require a breast examination that day or tapping out a pleural effusion, then I think everybody wins. And I'm not discounting the utility of a physical examination, but in oncology, the honest answer is, is sometimes, it is discussing a formal whole body PET/CT. And I'm going to get an awful lot from that right before I make my call. And it's probably not as important that day specifically that I put my stethoscope on the patient as it was maybe three weeks prior before the scan. RAMI MANOCHAKIAN: True. True. Great points, great point. And on a kind of related note, my next question I'll ask Dr. Rodriguez. At your institution, how have you or other providers adjusted to telemedicine during the pandemic? We've be doing it for a year. We learned through it. What approaches or maybe protocols or certain training or things that you've asked for from IT, or your own division or support staff, so you can accommodate patients in telehealth visits? ESTELAMARI RODRIGUEZ: So I think that we had a video, like a tutorial. But really, you learn by doing this over time, what works for your practice. One of the things that besides doing the prep work of really getting the technology in line and moving the visit alone and having our nurses speak to the patients before you go online, we have also learned that patients can take their own vitals. So I think that's one thing that we have incorporated. We have learned that we can talk about clinical trials and have some of those conversations that would have required a different visit at that point. And I think overall, the providers have appreciated that they can, once they get the system running, we can see more patients. And we can access them when we need to. And like you mentioned, some of these conversations are quick conversations, but they need to be had. And sometimes, you see a patient that had chemotherapy, and you would have liked to see the patient the week after just to check on, and really, to have them drive for an hour and wait for just a quick checkup, where you could do online. And that really has changed my practice and has allowed me to keep in contact with the patient more often, especially basic practices that don't have enough clinic space. Like some of our practices don't have enough parking. They don't have enough clinic space. So we really have adapted well to the telemedicine option to provide care for patients. But again, we still have to incorporate other things that we don't have, like the interpreters, the hearing, patients that cannot hear well. So there's things that we need to work on to make it more user-friendly. RAMI MANOCHAKIAN: Absolutely. Dr. Lopez, anything else you've done differently, or your team has done differently to adjust? ANA MARIA LOPEZ: So we had sort of a series of modules. But I completely agree that you sort of learn by doing. And I think that there are opportunities to bring in. So we're experimenting with this virtual waiting room, so that the MA comes in, sees the patient. The nurse then does what they normally have done, and then the clinician. And then similarly, at checkout, so that it's like including all of the pieces that would have taken place during an in-person visit and involving the whole team that normally engages with the patient. So I think, again, this is definitely evolving. And we're, I think, making it more like the regular in-person visit. RAMI MANOCHAKIAN: One thing I would add also, as a fellowship program director, we were at the beginning wondering, how do we include the trainees, the fellows, the residents? There are some providers who would say, I would just have the fellows or the trainees see them in-person and not do the video. But the longer we've gone through this, we realize this is actually an important training experience, and not necessarily, but here we go where we are we and the trainees have zero experience in this. So we kind of learned from each other and support each other. But there are also, I think having the trainee, the fellows in the room. Sometimes, we had logged in from two different computers. I think it helped and it also showed the patient that the team hasn't changed. We've had pharmacists sometimes join if there was some education needed. But I, again, needed some adjustment, needed some IT help and so forth. And we continued to learn through the process. Dr. Flora, I think there is a very important question that has been always posing itself during this year is, when it comes to billing and documentation, how has the use of telemedicine affected that? Many of you know actually maybe participated ASCO advocacy at the Congress, one of the major bills that we've been advocating for is future keeping of telemedicine. Because ultimately, as far as being able to build and generate the proper income since we continue to invest. And we're doing the same care we do for our patients but in a telemedicine mode. So how was it different for you, Dr. Flora? Any challenges there? DOUG FLORA: Well, you know, I participated in some of that lobbying. And I do it at the state level. And we just did it at the federal level as well. And I think it's great that the oncology community is coming together as our patient advocacy groups. Our first question, we established that it's time-saving. There's cost-saving advantages both for patients and payers. Helps with child care, helps with people being away from work. So it's actually a good thing for society in addition to the good thing to keep us afloat during COVID when they can't come to our office. The CARES Act was voted on and enacted March 6. And since then, we've kind of had the trust of the federal government to say, do what you can to take good care of patients. And for that to be sustainable, I think we've discussed that it has to be in an evidence-based fashion to say that we're not just accepting these things because it's easier care, but that we're actually making sure that we provide the same level of care that existed prior to the pandemic. And so some of the sustainability stuff that is in the proposed laws, we'll touch on that, making sure that we're still documenting well, making sure that as we build, we really are providing the service that we said that we were, which I think the majority of physicians take very seriously, to say that we did the work that we've claimed. And so we've all adapted with virtual physical examination. We've adapted with having the patient take their own heart rate or weigh themselves, as we've discussed earlier. I love the idea of a home oximeter. My wife bought one at the beginning of COVID, but most of my patients probably didn't. So as we move forward, we're seeing this move into research infrastructure for checkups on patients who are on trials at remote sites. And I think that the train has left the station, according to everything that we've seen from Medicare and our consultants who we've engaged in. Now we have to figure out how to make it work and make it sustainable. But it's not going to go away. RAMI MANOCHAKIAN: Absolutely. Dr. Lopez, any comments on the billing or the documentation portion? ANA MARIA LOPEZ: You know, I actually really love to do telemedicine from the documenting perspective. I have a lot of difficulty using the computer during the patient visit. I just don't feel right. So like right now, I could be typing and you might not see me typing. [LAUGHS] RAMI MANOCHAKIAN: We all do that sometimes. ANA MARIA LOPEZ: So, anyway, I do think, as Dr. Flora was mentioning, there are lessons to be learned. And we like working with our legislative colleagues to be able to have the sustainability. But yes, very important to keep the documentation in sync with the billing aspects. RAMI MANOCHAKIAN: Absolutely. Absolutely. And we're kind of coming close to our last question, which again, a good segue from what you just mentioned, lessons learned. You know, I think we all believe clearly that telemedicine in general and in oncology specifically is here to stay. What lessons, what kind of last notes if you want to mention? And I'd like to hear every one of you saying what lessons you've learned, what lessons you want to take moving forward so we can keep telemedicine and oncology, and continue and strive to provide our oncology patient with the best possible care? And I'll start with Dr. Rodriguez. ESTELAMARI RODRIGUEZ: So I think it's upon us to make sure that telemedicine breaks barriers, doesn't create more barriers to our current care. So I do worry about our older patients who already feel like they have been left behind by the whole technology divide. So I think we really have to work hard in understanding what's the best way to communicate with patients that have difficulty hearing, may not understand the technology. We have to develop better systems for them. But overall, I think it's a great addition. It does break barriers for patients that you cannot reach physically, or they may spend a lot of money coming in and driving and taking time from work. But again, we have to keep in mind that we don't want to leave parts of the population behind who are not easy to get into technology. RAMI MANOCHAKIAN: Great. Dr. Flora? DOUG FLORA: Well, as I mentioned when I said the train has left the station, the future is now. And so we can either have this thrown at us, or we can do it ourselves. And I would say that in our center, we're really looking to expand upon this. And we're looking more into more home care, and how can we deliver chemotherapy safely in the home? I think we would all be remiss if we didn't start to really look at the landscape of these devices that are available at home. You know, anybody who's ever worn an iWatch now knows that you can send them your own EKG to your own phone in a matter of two or three minutes. Why can't we get a pulse of a patient with an appropriate device? And these things are here and the economies of scale are driving these down. So eventually, in the next three to five years, I think a lot of these technologies will be democratized and in every patient's home, even the 65-year-olds, because it's a watch that their daughter buys them. And I think when we start to plan for things like that, we're going to find ourselves meeting the patients where they are, which is where they want to be in their living room, effectively and safely. RAMI MANOCHAKIAN: Couldn't agree more. Dr. Lopez? ANA MARIA LOPEZ: I feel like telemedicine is a new translational science. We're beaming people in wherever we can and seeing how it works and seeing the outcomes. And we've talked a lot about bridging the distance between patients and physicians, patients and clinical care teams. But there's also the opportunity to bridge the distance between clinical teams. So that's another potential benefit. And I think it's really made us better clinicians, because we're doing these exams now that are primarily observational. So I feel a little bit like Sherlock Holmes. Your observational skills, I think, are really sharpened with this opportunity. So I think there's a lot of benefit. There's a lot that we've learned, and there's a lot that we still have to learn. RAMI MANOCHAKIAN: Absolutely. Absolutely. Unfortunately, that's all the time that we have for today. Otherwise, really, the conversations have been so good that I could have taken this for hours to come. I'd like to thank every one of you for your participation in this episode of ASCO Education podcast. It was, I think, a very productive and insightful conversation. I think we all agreed that we're helping patients with telemedicine. And I think many of you, or all of you said it best, is that we learn from the lessons. We've built up on the strength that we've already come across, and then looked for rooms for improvement. And it's an area of research, as Dr. Lopez mentioned. And keep looking for how could we enhance this further, because I think we're going to keep doing it for a very long time. Thank you again, very much. I appreciate your time. [MUSIC PLAYING] ANNOUNCER: Thank you for listening to this week's episode of the ASCO E-Learning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

Recent approvals of PARP inhibitors mark the beginning of precision medicine for prostate cancer. Through patient case scenarios, Drs. Lisa Holle (Oncology Pharmacist, University of Connecticut) and Pedro C. Barata (Medical Oncologist, Tulane University) dive in-depth into appropriate use of olaparib and rucaparib in clinical practice, including patient and disease factors to consider. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us TRANSCRIPT [MUSIC PLAYING] ANNOUNCER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] LISA HOLLE: Welcome to the e-learning ASCO podcast on PARP inhibitors in prostate cancer. I'm Lisa Holle. I'm an associate clinical professor at the UConn School of Pharmacy, and I practice at UConn Health's Carroll and Ray Neag Comprehensive Cancer Center in Farmington, Connecticut. I'm joined today by Dr. Pedro Barata from Tulane University, New Orleans. PEDRO BARATA: It's great to be here with you. LISA HOLLE: Same here. PEDRO BARATA: So, Lisa, I know we'll be talking today about PARP inhibitors in prostate cancer. And it's kind of a kickoff, you know. What do approvals of the different PARP inhibitors for patients with advanced prostate cancer mean to you? LISA HOLLE: Yeah, this is a really exciting time in prostate cancer, because this is really the introduction of precision medicine in the treatment of metastatic castrate-resistant prostate cancer. So this is a group of patients, traditionally, who can benefit from PARP inhibitors that have not had good responses in the past to our traditional treatments. In fact, it really does allow these patients who would be eligible to receive PARP inhibitors to have an extended time on active therapy. Now, as we know with metastatic castrate-resistant prostate cancer, we can't cure the patients, but we can extend that time that they're on active treatment. In fact, in the two studies that were conducted, the PROfound study evaluating olaparib, and the TRITON2 study evaluating rucaparib, the progression-free survival time on average was about eight months. And in the PROfound study, which compared it to our new generation hormone therapies, that really doubled the progression-free survival time. And recent overall survival time was also improved by about five months. So this is really a significant advancement for these patients. And it really underscores the need that we have now for our metastatic patients to do germline and somatic mutation testing to see if they might be eligible for these treatments in the future. So Dr. Barata, who do you think could best benefit from the PARP inhibitors in prostate cancer? PEDRO BARATA: Yeah, and also, it's a great question, by the way, great introduction to the topic. And you indeed touched on something very, very important. And I think it's a perfect segue way for your question, which has to do with can you identify the good actors or the patients who are likely to respond, right? So when you think about how these drugs were developed, if we started by classifying this group of genes known as DNA repair genes, right, who have this job or function of repairing defects at time of cell replication. And so among these different genes, we start talking about BRCA, BRCA1, BRCA2, ATM, CDK, you know, RAD51, FANCA, et cetera. And so it seems like patients who harbor a defect in one of these genes are actually more likely to respond to these therapies. And these therapies, by the way, they inhibit the PARP and the enzyme that helps with burying the DNA, if you will. And so, you harboring a defect in one of these enzymes actually helps you to kind of amplify the benefit of this therapy. So what I'm really describing is a test who can find those defects, those gene differences. And we can do it in both ways. We can test the genes patients were born with. We call that germline testing. And we can also test a tumor for dose alterations. And that's also known as somatic testing, right? And we now know that germline doesn't tell you all the story and somatic doesn't tell you the full story. And so getting both tests seems to be helpful because it's a way of not missing the biomarker positive patients, or in other words, patients with DNA repairs, who are, again, likely to respond to these therapies. And so I would say, among these, definitely, patients with DNA repair defects. And we start learning a little bit more that not all the genes defects are the same, I mean the same in terms of efficacy signal. I guess we can talk about that a little bit later today. But I have to say, we expect somewhere 20% to 30% of patients who harbor dose genomic alterations. And so we are talking about a subset of patients within the group of advanced prostate cancer who really harbor those gene defects, and based on the data we have today, are destined to do better on these agents. Now if we don't test, we don't find, right? And so that's something that I think the clinics overall across the country and really, around the world, are now adapting to develop an easy way to start offering germline and somatic testing to those patients. Because it does impact our decisions. And so I kind of-- I just alluded briefly. And you did say, Lisa, you did talk about PROfound and TRITON that developed, respectively, olaparib and rucaparib, right? Do you have any thoughts about factors that makes you choose one versus the other? Is that something that you kind of use in clinic and to go through that thought process? Tell us a little bit how it goes when you get to pick one agent. LISA HOLLE: Yeah, I think as we think about new agents that are available for each of our individual patients, we have to think about patient characteristics, I think is one big factor, such as comorbidities. For example, in the PROfound study, I think they had an instance of deep vein thrombosis and pulmonary embolism that was relatively small, but it was in the range of 4% to 7%. And so I think in a patient who might have a history of a recent PE or a thromboembolic condition, you might shy away from using olaparib if they could receive rucaparib instead. I think the prior therapies that they have received too is also really important. So both of these trials looked at patients who had advanced after receiving either enzalutamide or abiraterone. And then the TRITON study evaluating rucaparib, they also had to receive at least one taxane therapy. So I think you need to make sure that they've progressed on one of those therapies. You might try olaparib before a taxane in that patient population. PEDRO BARATA: So basically, you're saying-- because I think it's a very important message-- is not that we believe agents might be different mechanistically, right? But the way we develop drugs in the oncology world is based in the setting they were developed, right? So you're basically describing different patient characteristics that were enrolled in PROfound and TRITON, and how that led to different approval specifically regarding chemotherapy. Is that it? LISA HOLLE: Right, exactly. And so I think when you're trying to decide between two therapies that have similar outcomes, are used in a similar population, and trying to figure out which one might be better for that particular patient, I think these are some of the things that we think about. Certainly, insurance approval could be a possibility, although I would expect that insurance would cover both of these agents. They're FDA approved. They do have some different indications that we can talk about a little bit more specifically as we talk about the specific testing that's done and what mutations were found to be most beneficial from these agents. But also, I think performance status is something to consider. So when we get to later lines in therapy, sometimes, our patients have poor performance status. And as with all clinical trials, we enroll patients with good performance status. I think the PROfound trial enrolled ECOG 0 to 2, and TRITON2 enrolled 0 to 1 performance status on the ECOG scale. So again, well-performing patients. It doesn't mean that our performing patients can't receive these drugs, but they may not have the same outcomes and may have more toxicity. PEDRO BARATA: Now it's interesting that you brought up access. I don't know your experience with that. I actually had a story, and I can share now or later. LISA HOLLE: Yeah, absolutely. PEDRO BARATA: So here in our clinics, we do test everyone. And we'll talk a little bit about that in a minute. And so this patient was a BRCA, a BRCA2 positive patient. And we tried at the time, we applied for olaparib for him. And unfortunately, we were not able to get it due to insurance restrictions at the time. This was prior to the FDA approval. And so we got to be creative. And we went with a platinum-containing regiment as an alternative. And it turns out, it worked really well, as we know. I mean, there's significant data out there. But basically, demonstrating an increased activity of platinum-containing regimens for patients with DNA repair gene defects. And so anyway, so that patient did respond well. And so I think he completed-- he got some carbo plus cabazitaxel at the time. And he completed six cycles, went on observation for while, on a chemo break, as we call them. And then he progressed a few months later. And at that time, we reapplied for a PARP inhibitor. And it got approved that time, actually. So we got rid of the obstacle that we had the first time around, that we encountered the first time around. And so actually, that patient is still on olaparib and doing well. But I think that speaks a little bit to what you were saying or referring to, that sometimes, there are obstacles that we have to be aware of. And definitely, access to medication is one of them. LISA HOLLE: Yeah, absolutely. And I think this highlights a good point that we're having in all of our patients with cancer right now, is as the studies come out-- so GU ASCO was just a month ago. Data comes out and the guidelines aren't updated right away. And during that period, when we know we have an effective therapy that could be used, that's the time, I think, and even a few months after that is when we have the most difficult time with insurance approvals. And then, of course, the FDA indication also can cause a lag in insurance approvals. But certainly, I think that also shows that we can, as many of us have done, had a peer-to-peer with an insurance company to ensure that they understand the data and can approve these therapies. That's another way that we can go about that. I think one other really important thing to think about these drugs are that they're dosed twice daily. So adherence could be a problem for some patients. Most of our patients have significant comorbidities. They're older adults, have multiple medications. So it's just an additional pill burden. And as we know with targeted therapies, adherence is really important to try to prevent the resistance that will ultimately develop, but try to prevent it from happening sooner. PEDRO BARATA: Right. LISA HOLLE: So I guess we probably should talk a little bit more about the testing that needs to be done and how we go about testing our patients. So could you share your experience with that, Dr. Barata? PEDRO BARATA: Yeah, for sure. I mean, that's truly, truly important. And thank you for highlighting that again. So as I was referring to earlier today, there are two types of testing, right? Germline and somatic testing. So the germline can be done with, for example, a simple blood test. And there's a bunch of commercially available assays that can do that for us. In regard to somatic testing, we can do it in the tissue. We can use a fresh biopsy or archival tissue, or we can do a liquid biopsy where we basically find circulating tumor DNA that's at the time of-- it's also a blood drawn, basically. So in prostate cancer world-- and I think that that's familiar to a lot of folks who treat prostate cancer-- they do know a lot of times, archival tissue is available from many, many, many years ago. And a lot of times, we cannot get fresh tissue or tissue that we feel represents the reality of the tumor today when we have the patient coming in to see us, for example, right? So I guess access to tissue is often a problem. And as you were saying, Lisa, both PROfound and Triton and other really biomarker positive studies, they often start based on tissue, not based on liquid biopsy, right? So the question is, in the absence of tissue, what can we do? And there's an emergent number of studies have shown good concordance between liquid biopsy and tissue. So I'll tell you what I do. We do favor tissue sequencing. And there's also a number of commercially available assays out there. And when I don't have tissue available and I really think we should do somatic testing, I use the liquid biopsy as a surrogate, if you will. It's not perfect, right? Because unless the tissue and liquid biopsy are kind of collected around the same time, and even though the panels are different-- so there are all these differences in there. But I think if we find, in this case, a gene defect with a good allele fraction, at least in my experience, I had that a few times. I did not encounter obstacles to access to a PARP inhibitor. But I still favor tissue because that's where the data was developed. And so that's just my style, right? I try be data driven as much as possible in all germline, right? If I have a germline that more than likely is going to be the tumor, right? Because all the cells wouldn't have it, but not necessarily. But anyhow, if I have a germline test positive or tissue positive, I'll use it. If I don't have tissue and I have liquid biopsy, I would still try it. But that's kind of my go-to, right? Now I do-- based on my conversations with my colleagues from the community, there's a little bit of concern about what to do with the results, meaning if you don't test, you don't know. But if you test and something positive comes back, you need to sit down with your patient or at least provide some kind of explanation and understanding. And some of us more than others are a little bit less familiar with some of the genomic alterations we can find. And I don't know all of them, to be honest. And they can create a challenge. So sometimes, we don't test because concern about the results. I would like just to highlight the fact that these commercially available assays, they do a good job, even a better job now than before, in terms of providing genetic counseling sometimes online or over the phone. And actually, some of my patients have used that in addition to just kind of go through the results with me. So that's something to be aware and it's simple to do, right? And we talked a little bit about reimbursement, especially before the approval. So approvals is based on the setting, right? So if I want to do, for example, rucaparib to patients who did not get chemotherapy, it can happen that insurance will, the payer will say, this patient needs to receive chemotherapy first. Because that's based on how TRITON was designed, right? And so you have an alternative, which would be olaparib, that doesn't require prior chemotherapy. And that doesn't speak anything, as you said, regarding which agent is best. And I'll defer, you did a great job in terms of breaking down in terms of safety profiles and the differences. But my point is, knowing where the medication was developed helps when we ask for that therapy for our patients, right? And then, the last point I would like to make is in addition to the therapeutic implications, especially germline testing, I think it's important to be aware of the familiar implications. And so, some way or the other, germline assays, test assays do provide support for family members to get tested. So here in clinic when we test them, basically, family members get tested for free if the patient is positive and as long as the patient agrees with it. Because he's actually the one who provides us the information to reach out to family members. And so I'm just thinking an example where we found a patient who happened to be BRCA1. And then we were able to go after his family and test his family. And we found another two positive cases. And two females, one in the 40's, one in the 30's, I believe. And so I actually think we did change the future for those two individuals. So the implications that go beyond the patient in front of us are actually huge. I have another case in kidney with a genomic operation, where we have, since this patient was diagnosed-- and it's not a kidney cancer conversation-- but since this patient was diagnosed, three others developed cancer. And we found another four patients who harbored that genomic alteration. In that case, it was a path one. But I'm just sharing the potential implications for family, which I think is huge. Because our care goes beyond the patient in front of us, right? And sometimes, it can impact what we do with the family. So that's-- so the bottom line, to me, is if we don't test, we don't find. It's OK not to know everything about the test results. And there's more resources out there that can help us with that. And the implications of testing are significant. LISA HOLLE: You make an excellent point on those things. The other question I had for you is, you know, I think the guidance right now is that we do somatic testing at the time of development of metastatic castrate-resistant disease. But there is also some suggestion that we should repeat that somatic testing when somebody progresses after a treatment, right? So do you do that routinely? PEDRO BARATA: Yeah, that's a great question. That's a great question. And obviously, I'm biased because we do research in addition to standard of care approach. So I have to say, what I do, and here at Tulane, we basically test everyone for germline at time they step in the clinic with metastatic disease. We have the discussion for recurrent disease no mets, and then for high risk as well. So that's in regards to as far as germline testing goes. In terms of somatic testing, I also had one upfront. The reason why I get, if I have tissue and I'll use a tissue if I don't. I do liquid biopsy before I start them on systemic therapy. The reason why I do that is because it helps me to plan. And I think as one of my former mentors used to tell me, I guess, was that as an oncologist, we always like to anticipate. And we always have a plan B. And I love anticipate. I hate surprises. I only like surprises at home. I don't like them at the office. And so having that information allows me to plan things when option A won't work for them. So a lot of times, I get the testing here back. And I'm not even doing anything with it in terms of PARP inhibitor, for example, right? Because to your point, they are approved in the metastatic castration-resistant setting. And a lot of times, they do it for castration-sensitive settings. So what do I do afterwards? Well, that goes a little bit in the research side. We do a lot of serial sequencing, tumor sequencing, if you will. Germline, we only do it once. And the reason for that is we do see changes over time, meaning exposure to treatments has the ability to impact the molecular phenotype or the molecular makeup of the tumor. So that's the reason why we do it. Does that happen a lot? I don't think, or at least that it's targetable, the answer, I don't think it is. But for me, we published something about MMR/MSI, where we were show that MSI might be acquired over time. It goes beyond the germline. And so as an example, if I find one additional patient that is able to get benefit from a target therapy or immunotherapy that would not otherwise, and would never offer him the therapy, to me, that's a lot. That's very significant for that patient in front of me. So having that repeated, it's important in that perspective. It's not ready for primetime in my opinion. I think we should. If we can, I think we should do it. But right now, the data is still lacking. The strong data is still lacking to provide guidance in terms of how often should we be testing these patients and when, right? And after what therapies? So those questions remain unanswered, which are very important questions. I just say, if you have the ability to do it, why not do it? And so, Lisa, so it's kind of a good segue way to the next portion of it, which has to do-- we talk a lot about olaparib, rucaparib, similarities, differences. Can you basically expand a little bit about how do you choose them, and a little bit about the approvals, how that impacts your treatment decision? I know you talk a little bit about it. But can you highlight us on the safety profile and toxicity a little bit more? LISA HOLLE: Sure. So you know, just to recap, the olaparib, which was evaluated in a PROfound study, looked at homologous recombinant repair gene mutations. So it sort looked at a broader group of mutations and had most benefit in BRCA1, BRCA2, and ATM, although some of the other mutations also had some benefit, and was studied after progression on enzalutamide and abiraterone. So that's what its indication is for. Rucaparib is indicated for patients who have a BRCA mutation, germline or somatic, who progress after abiraterone or enzalutamide and at least one taxane. So that's sort of the difference in terms of the indications and how they were studied. As I mentioned, they both had good performance status patients. So we have to sort of think about that again when we're thinking about overall use of these drugs. But in terms of differences, some of the key things that we think about are potential for drug interactions. As I said, many of these patients are on a lot of different medications. Rucaparib has several different cytochrome P450 interactions that can occur. So it has more potential for drug interactions than olaparib does. Olaparib needs to be dose adjusted for patients who have renal dysfunction, has that incidence of VTE that was higher than the comparative arm in the PROfound study. So that's something to consider. And then, I think with olaparib, there are some other laboratory abnormalities that we don't tend to see with olaparib. So with rucaparib, we can see LFT elevation, elevations in triglycerides, alkaline phosphatase, so just something to be aware of. It doesn't often require a necessitation of discontinuation of the drug, but can happen and also is associated with a rash. So those are some of the differences between the drugs. PEDRO BARATA: Yeah, that's a great review. In clinical practice, and I know you've used both, right, anything that you think differently? Like, when you have a patient on olaparib or a patient on rucaparib, is anything that is a red flag for you, or at least, like, rings a bell and say, hey, should be thinking about this? You know, tells us what you're thinking? LISA HOLLE: I mean, one thing that for those providers who work with multiple tumor types, so we use these drugs in ovarian cancer patients, obviously. And in that population, there actually is the risk of developing myelodysplastic syndrome or acute myelogenous leukemia. And so far, at least with the data that we have in the PROfound and the TRITON studies, we didn't have any incidence of that reported to date, even though these patients had received potentially some other chemotherapy agents that could put them at risk. So I think, if you use these drugs in other settings, that might be something that you're concerned about but we haven't seen in the prostate cancer population. And then, I think we do see cytopenias that can occur just as a result of the mechanism of drug. And we have to monitor the complete blood count with differential in these patients. But I think as oncologists, we're very familiar with managing these patients. They often don't need dose adjustments or discontinuation due to cytopenias that are relatively mild. They also can cause nausea. So we just have to make sure our patients have an antiemetic at home. And we continue to make sure that they're benefiting from either using that or understanding that that doesn't necessitate skipping the drug because they're not feeling well. So it just requires some sort of monitoring of those patients. I think those are the biggest things that we tend to see in our patient population. PEDRO BARATA: Yeah, no, that's good. And you remind me that those are very important points safety-wise. I was thinking, if I have a patient in front of me that has not received chemotherapy, for example, and he's now progressing on abira/enza, right? And let me say, because I just got a patient like that recently. And so when would be the time when I would probably not choose a PARP inhibitor and I would choose something else, right? And so, as we learn a little bit more about the different homologous recombination gene defects, we start to understand that not all the dose defects are the same or mean the same in terms of what we expect from these therapies. And so I was thinking of a case where just based on the genetic information he had, so we basically came for a trial second opinion. He actually was-- he couldn't make the trials. But he happened to harbor a CDK12, which is approved, by the way. If we look at PROfound, right? As you mentioned, this would be a patient-- we actually had a report, when I got the report back. And he was reading the report. Good, Doc, I'm going to get a PARP inhibitor, because they were there, right? He said CDK12 benefit PARP. And I was actually not convinced that would be the best option for him. And I'll tell you why. I mean, he actually was symptomatic. And I basically showed him the breakdown of the PROfound data that basically suggests minimal activity of a PARP inhibitor for those patients, for example, right? Which is a little bit interesting to be in clinic with a piece of paper saying you're going to benefit from something. And the physician might be telling you, well, let's not go so fast, right? And this is why. And I pulled PROfound. I told him the story about TRITON. They had a CDK12 cohort that was discontinued due to lack of activity. And so I end up-- I plot for him a different approach, a chemotherapy approach would be a better choice for him. And I did not go with the PARP inhibitor. And I think, to me, as we learn more about what the different genomic alterations do mean and what we expect with them, I think we're going to have these discussions more and more, meaning it's not like, oh, you have a checklist of homologous recombinations in the facts. You should get the pill. I think the discussion goes beyond that and it takes into consideration several different factors. I just gave an example about the type of gene, but also what you just said in regards to safety, in regards to patient comorbidities. And so this is a great option in my eyes. It's a fantastic option, actually. We have survival data now from PROfound as well, right? It makes them live longer. It prolongs time to progression. And so it's definitely a huge advantage that we got in the prostate cancer world, one of the recent developments that are truly meaningful to patients. But I don't think it's still applicable to all of them, right? And so I'm just-- as you were talking about safety, et cetera, I just remind myself of that case because it reminds me, not all genomic alterations mean the same. And speaking of that, it will be interesting to see. One of the things that are coming up in the future is we do have these broad studies that test PARP inhibitors for unselected group of patients regardless of their molecular phenotype, right? So that will be, to me, that's a very interesting group of trials. Because we don't know whether or not it's going to be-- we're going to see an advantage there. But I think it's very interesting to explore that concept because it would take us beyond a select group of patients based on the biomarker to a more broader application and use of those therapies in an advanced prostate cancer arena. I don't know your thoughts about that, Lisa, and whether or not you want to share other thoughts about what's coming up. LISA HOLLE: No, I think that's an excellent point. And it'll be very interesting to see the results of those trials. Before we talk about some of the other things that would be interesting and what we hope to see from these drugs, it reminded me when you were talking about that patient who you chose not to use a PARP inhibitor, even though they had a HRR mutation. Do you, in your clinic, allow for more time in those conversations where you have to go over the results of their sequencing? PEDRO BARATA: Yeah, great question. So because I do it in advance, right, I do it and I do it over time. So yes, the answer is yes. We go over the genetic information over and over again. And that's one of the reasons why I do it as soon as I meet with the patient because it allows me-- I don't expect this information to be well-captured the first time. It's very complicated. And sometimes, we still struggle ourselves in understanding exactly that what that means. And so repetition is very helpful, and to go over the data and just explain the data differently. And so that, I mean, that happens a lot with me. So I do know, I have a number of patients who have constriction-sensitive, who I know they harbor BRCA or whatever, CDK12 or something else. And I do bring it up to our meetings, right? I do say, listen. It is great. This is working great for you. Remember, we have this genomic alteration that does this. And this opens the door to more options in the future, et cetera. So I try to remind the patient and myself of that over and over, so that if we have to use that information, he's already familiar with it. I hate to chase the tumor. I hate to be behind a cancer. Like, you know that feeling when the tumor is progressing, you're chasing the cancer to regain control of the disease, right? So I like to, or try to at least be one or two steps ahead, anticipating what might happen, right? And there's a lot of factors that help us to do that. But certainly, testing them early helps us to accomplish that. So that's something that I do. And it helps me as well to be more comfortable in clinic. LISA HOLLE: Yeah, we do a similar thing in our clinic. I think it's really beneficial to do that because I think patients sometimes hear about precision medicine. And they feel like if they have this super medication that matches their tumor, that's going to be the silver bullet to their treatment, right? And that, I think, is something that we have to often play down and explain what this really means, and that this is something that can be used later on and isn't quite as magical as they think it might be. So I think that's a good way to do it. I think one of the things that we don't know, and this is true of most targeted agents, like if you fail one PARP inhibitor, can you have a benefit from the other PARP inhibitor? Or should we use a platinum-based therapy first before a PARP inhibitor? And I think those questions are interesting and yet to be answered. PEDRO BARATA: Yeah, that's a great point, right? I mean, I have the feeling that they might not work the same way, right? And so we don't have data so far that categorically shows us that one PARP after the other would work. However, we can look at our friends from other tumor types and see that that approach has not been followed. And so I wouldn't expect that to be the case. In regards to platinum and PARP, that's a different story. I can see in the future, patients receiving platinum after PARP inhibitors and not the other way around. I mean, the other way around probably would happen if there's some difficulty with access to the PARP therapies. But we tend to use novel therapies more than the old ones, right? And platinum has been around for so long. And it's still a great therapy, especially combination, right? Because we now have got a piece of data we have the data from Houston group with cabazitaxel combined with carboplatin, right? Which was published about two years ago. And so I do think, I have to say, I'm biased because we're doing a little bit of research on that. I know data will come up to answer that question will be better, real world data in terms of activity of platinum post-PARP activity of PARP plus platinum. And we'll see that data more and more over time. But you're right. We don't know the answer for sure. And I'll be honest. Until I know it's definitely a no, I'm probably going to try if I don't have another option, right? So that's how we come up with those cases. And then we try to put them together and report their outcomes. And that's one kind of question that's out there. There's still an answer, to your point. Another one would obviously be we keep talking about PARP inhibitors. That's how great they are. And they got approved in their specific setting. The question is, are they still benefiting patients in different settings? Like, hormone testing, for example or unselected group of patients, as we talked about earlier. And those type of questions remain unanswered. I do know they will get data that will help us to answer those questions. But that's definitely something that we'll pay attention to as we move forward. And finally, combination regimens are being tested with different PARP inhibitors, including radium, including immunotherapy, chemotherapy, et cetera. So novel and monotherapies, I do think that it will be very interesting to see whether or not throw the sink with a PARP inhibitor in there versus sequencing the different therapies that we have available provides a different advantage to patients. What are your thoughts, Lisa? LISA HOLLE: Yeah, no, I think all of those things are considerations that are likely to have answers in the relatively near future as we get through those studies. I think it's interesting to think, like, is there a group of patients who don't have metastatic disease, probably, who have these germline mutations that could maybe benefit from a PARP inhibitor very early in treatment so that they don't progress to metastatic disease? But that obviously is quite far in the future in terms of where we might have these drugs, but not something that we should consider and evaluate at some point. I think novel other PARP inhibitors, I'm not aware right now of things advancing quite quickly in that area, but that's another area where we might have new agents that could have similar mechanisms of action that could be useful as well. PEDRO BARATA: Right. No, that's great. That's a great point that you bring, thinking about the non-metastatic space, right? I feel like today, we've been talking a lot about metastatic in this setting. But you're absolutely correct. There might be an impact in the non-metastatic setting as well. No, I mean, I think this was a great conversation. It's always a pleasure to talk to you about any topic, really. But it was great talk about prostate cancer. Let me ask you, Lisa, do you have any final take-home points for folks who might be on the other side hearing us? LISA HOLLE: Yeah, I think the biggest thing is that this is an exciting new era, right, in this metastatic castrate-resistant setting, and that we need to be mindful of the data that's coming forward. So we have just recently, the overall survival data published from PROfound and updates that continually come out. So I think it's important just to stay up-to-date with this information to make sure that you're aware of the toxicities of these new drugs as we continue to use them. And don't be afraid to have those conversations with patients about how this might be something that could be part of their therapy in the future, but have those conversations early. PEDRO BARATA: Yeah, no, that's great summary points. For me, I would love to highlight the importance of testing. And I think we covered it. The safety, no less, that you did a great job at telling me and the folks out there about it. And exactly what you just said, what's coming up in the future. And these are, for sure, great, great news for patients who, unfortunately, were diagnosed with advanced prostate cancer. All right, well, Lisa, it was a pleasure talking to you today. And thank you for ASCO for putting this program together and allowing us to discuss a little bit about PARP inhibitors in prostate cancer. So thank you. And have a good day. LISA HOLLE: Yeah, thanks, Dr. Barata and ASCO. This was a great conversation. Thanks. PEDRO BARATA: Thank you. [MUSIC PLAYING] ANNOUNCER: Thank you for listening to this week's episode of the ASCO e-learning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.