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Nov 7, 2019

ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Lauren Davis and joining me today is Dr. Andrew Epstein of Memorial Sloan Kettering Cancer Center. Dr. Epstein served as the program committee chair for the recent Supportive Care in Cancer Symposium. Dr. Epstein, welcome to the podcast.

Dr. Andrew Epstein: Thanks for having me.

ASCO Daily News: So the final Supportive Care Symposium has concluded. How has this meeting impacted oncology care as a whole?

Dr. Andrew Epstein: It's been a really nice opportunity to answer that question. Looking back at the five years that we've had the Supportive Care Symposium has put it into context that we've really grown as a field. Supportive oncology has been one of collaboration, teamwork, and research between oncologists, palliative care clinicians, and researchers, and many others.

Dr. Andrew Epstein: And I think one main takeaway is that all the stakeholders involved-- patients, families, clinicians, researchers-- have collaborated and really worked as teams in order to research and improve better outcomes for patients and families living with serious illness. And I think over the last five years, we've really arrived at a much better understanding as a field, and even as a broader community, that palliative care is something that can and should be used early and often. And it really cements the synergy between oncology and palliative care as something that can improve outcomes for patients with cancer and their families, and not mutually exclusive from one another as was once often thought.

ASCO Daily News: Absolutely. Were there any sessions that were of key interest to you?

Dr. Andrew Epstein: There were. I am biased, of course, as having been the program committee chair, but I really think that the audience came away with a lot of education into the state-of-the-art practice and research in the field. And I'd like to discuss several sessions if time permits.

Dr. Andrew Epstein: Perhaps one of the most interesting ones, the session on CAR T-cell therapy, which was called "Driving Palliative Care Forward Into the Era of CAR T." And it was a good example because it's one of the many, if not the flagship, emerging novel therapeutic we have in oncology highlighting the need for sufficient knowledge of such a novel therapeutic and a way for not only oncologists, but palliative care clinicians to understand novel therapeutics and the way that patients and families are going to experience cancer and cancer treatments.

Dr. Andrew Epstein: And so there were a wonderful handful of people on the panel and presentations given. And Dr. Jagannath from Mount Sinai Hospital in New York City gave a very nice overview of the therapeutic, as well as toxicity landscape from CAR T-cells. And we see that toxicities remain a large issue and challenge for clinicians, and patients, and family. Among others, fever, as well as neurotoxicity often related from the cytokine release that occurs after the initiation of the therapy presents a major therapeutic challenge for all involved.

Dr. Andrew Epstein: And so there was ample discussion and review of how steroids may be used, but can also unfortunately downregulate the therapeutic effect of the CAR T-cell therapy. So of the several issues moving forward in this field, one of them is if it's possible to give medication such as steroids before CAR T-cell therapy in order to mitigate the side effects.

Dr. Andrew Epstein: And there was a really excellent presentation that followed by Dr. Areej El-Jawahri from the Massachusetts General Hospital about how we navigate prognostic uncertainty with novel cellular therapeutics, such as CAR T-cells. And it was built upon the foundation, which I and many people are fascinated by, that prognostic awareness is a crucial and yet really tricky thing in oncology for patients, and families, and clinicians. Specifically, we know that prognostic awareness helps patients and their families decide how they want to spend time and time that is often limited for patients with cancer.

Dr. Andrew Epstein: And the challenge is how we cultivate prognostic awareness in many settings of oncology, particularly this one where someone with a serious and often rapidly progressing advanced hematologic malignancy might want to spend their time and how we, as clinicians, can cultivate adequate prognostic awareness during that time.

Dr. Andrew Epstein: And making matters even more complicated is that CAR T-cell therapy is a treatment for which there are strict entry criteria and there's a somewhat binary nature, as Dr. El-Jawahri commented on, of the treatment of CAR T-cells. It's often a last-line therapy. And in a very rapid clinical-paced setting, as she calls it, we're in a race against time often. And so there's a binary nature to this pretty complex rapid course of the treatment either working or not working. And the fact that we're not good yet at predicting who it's going to work for and for whom it won't really makes the issue of prognostic awareness all the much more challenging in this setting.

Dr. Andrew Epstein: So I think it's a good example of how we have to always hope for the best and prepare for the worst. And while that's often scary and challenging for all of us, especially patients, and families, and clinicians communicating about these things, we really need to try to have patients be as informed as possible about what the medical situation is, what the toxicity and risks of treatments are, and how to hope that we get the best outcomes for them, but also be prepared by knowing what's important to people and what their priorities are for whatever outcome may come, including if not especially if it doesn't give us the outcome that we want. And so I thought that was a really nice session that we had.

ASCO Daily News: That's great. What about some other sessions? Was there anything that really stood out to you?

Dr. Andrew Epstein: Well, continuing on the notion of informed consent, particularly continuing on the notion of Massachusetts General Hospital's research team, Dr. El-Jawahri also was able to present results of original work that she and her team did. Specifically, there was a fascinating study of a randomized trial of a hospice video decision aid for patients with advanced cancer and their caregivers built upon the context here that patients infrequently use hospice and when they do, they often have a short length of stay or amount of days in duration that they are enrolled in hospice, once they enroll in hospice before the end of their life.

Dr. Andrew Epstein: And this team of researchers have done really effective, engaging work on video decision aids, which have shown to offer realistic images for patients in order for them and their families to envision hypothetical states, such as medical care states. And so in this specific study, the researchers had created a video to investigate whether a video about hospice and what it entails can inform patients and caregiver preferences for hospice care.

Dr. Andrew Epstein: And so this was at a single center and was 150 patients, but it was randomized patients either hearing a verbatim script about what hospice entails versus hearing a script and seeing related images about what hospice entails. And after the intervention, patients randomized to the video arm did have an increase in their hospice preferences, although this was not statistically significant compared to the control arm.

Dr. Andrew Epstein: Nonetheless after the video intervention when patients were better educated based on their results of their knowledge of hospice, they actually were more likely to use hospice care. And so while that wasn't the primary aim of the study, it was an interesting signal that came out from it and one that should be researched in multicentered studies and larger studies moving forward to answer the question as to whether informing patients about what hospice entails can actually lead to more hospice use and other outcomes, like satisfaction with care and other indices for patients and families. So that was really important and exciting research that we saw.

ASCO Daily News: That's great. We hear a lot about when to talk to patients about long-term treatment or next steps. So what new technologies are being utilized to help with patient care?

Dr. Andrew Epstein: Just like the hospice video decision aid that we had talked about, there was interesting work presented in the same session by Dr. Ravi Parikh and his colleagues from the University of Pennsylvania looking at machine learning. Specifically, the presentation was on the derivation and implementation of a machine-learning approach in order to try to prompt serious illness conversations in the outpatient setting in oncology.

Dr. Andrew Epstein: And machine learning, as many are becoming aware, is something which has been tried to be applied to structured data elements, including structured elements that exist within the electronic medical record and many medical centers. And the notion was that this might result in more accurate identification of patients who are at risk of short and long-term death, and the thought that these models might outperform what population-level studies, like RCTs and registry data, estimate patient's mortality.

Dr. Andrew Epstein: And so while this was an initial study with some limitations being from a single center and other limitations in terms of what serious illness conversations are and how they're conducted, it did show interesting findings that at the 180-day mark, mortality was about 50% in patients who were flagged by the model, using different clinical and other variables. Those patients who were flagged as high risk did have around a 50% chance of death at 180 days, whereas it was only around a 3.5% mortality in patients who were flagged by the model as low risk.

Dr. Andrew Epstein: So the authors had concluded that this seems to be a reliable way to discriminate among patients in the general oncology outpatient setting at this academic health care system for machine learning to predict short-term mortality. And so while larger and validating studies are needed, this was an interesting foray into this relatively new technology of machine learning.

ASCO Daily News: Absolutely. Let's pivot now and talk about integrative therapies. I know there was a session about medical cannabis in patients with advanced cancer to assess impact on opioid use and cancer-related symptoms. Could you speak to that one?

Dr. Andrew Epstein: Sure. This is a really hot topic. Cannabis has been something not only in oncology, but in other arenas of our lives in general as something which is thought to both help disease, as well as help the symptoms of disease and the toxicities from treatments of disease, including in oncology. And as oncologists, I am daily receiving questions from patients, families, and others about the impact of cannabis.

Dr. Andrew Epstein: And so we were thrilled to have a session on cannabis, as well as to have Dr. Dylan Zylla to present work on their study, which was a randomized trial of medical cannabis in patients with advanced cancer in order to assess what impact it had on the use of opiates for cancer pain, as well as cancer-related symptoms.

Dr. Andrew Epstein: And so while this was a small trial of only 30 patients participating and while there was some drop out of patients due to illness, it was really nicely done in terms of a randomized study between what they used as an early versus delayed onset of one or two formulations of medical cannabis. One was CBD and the other one was THC. And again, despite the limitations, there was the interesting signal that this may be helpful. Specifically of the early cannabis users, almost half experienced at least a 20% reduction in the amount of morphine or other opiate equivalents that they used for their cancer pain. And this was compared with a 0% reduction in a morphine equivalent use for patients in the delayed group.

Dr. Andrew Epstein: And they also saw that cannabis was overall well-tolerated, and therefore they appropriately concluded that cannabis-- medical cannabis, that is-- may lead to improved pain control among other symptoms and lower opiate requirements-- an area of critical import for patients and families with cancer and one which certainly will continue to be studied in many different avenues. That was an exciting area of integrated medicine.

Dr. Andrew Epstein: And I'll also comment that another type of integrated medicine from the psychosocial side of things was investigated. We had an entire session to conclude the symposium on psychosocial interventions. And one that I'd want to comment on was excellent work done by Dr. Kathrin Milbury and her colleagues from the MD Anderson Cancer Center in Texas.
And they did a randomized trial of mindfulness and meditation in not only patients, but also their loved ones in patients with lung cancer, notably patients with advanced lung cancer. So this is a challenging population in which to perform palliative care and psychosocial research given the symptom and other morbidity burden that patients with advanced cancer have.

Dr. Andrew Epstein: And so this was appropriately planned as a pilot study, one of the outcomes being acceptability. And this randomized trial showed that there was an acceptability to patients with advanced lung cancer, as well as their loved ones, with this psychosocial intervention entailing mindfulness and meditation sessions. And there was a signal of benefits for these interventions that were done. And the authors appropriately conclude that further larger-scale studies are necessary in order to better assess the effectiveness of the psychosocial interventions. So that was really interesting work as well.

ASCO Daily News: Yeah, I think it's great that they included the spouses and loved ones in this as well, since it affects the entire family. So what do you think is on the horizon for supportive care going forward?

Dr. Andrew Epstein: Well, we've got our work cut out for us. And we're really excited as clinicians and researchers about the things on the horizon. I'd say a few things. Particularly, we're a team and this collaborative-based approach. Let me say that again. We are a field that emphasizes collaboration and teamwork-based approaches, not only into the care we deliver every day, but how we actually research what mechanisms and therapies might be beneficial for helping patients and their families with serious illness, like cancer.

Dr. Andrew Epstein: I think the topics that are fascinating moving forward are number one, prognostic awareness and how we communicate about that, not only in the advancing era of molecular therapy such as CAR T-cells, but also how we enable high-quality teamwork and trust between patients, families, and their clinical teams given the research that we've seen that sometimes, a lower degree of prognostic awareness can be associated with a greater degree of trust with clinicians. So how do we best make sure the patients know information, but also feel known as people so that they can feel good about and trust the care they're getting and the teams that are delivering their care every day.

Dr. Andrew Epstein: And secondly, I think the mechanisms of cancer and cancer treatment, as well as other side effects from cancer treatments will continue to be borne out with ongoing research. And this would be both into treatment that are old, as well as more emerging treatments. So whether it's the oxaliplatin-induced peripheral neuropathy, which is a now relatively old and still dogged problem for oncologists and palliative care clinicians, or if it's newer therapies like CAR T-cells. What are the mechanisms of these toxicities and how can we best research better treatments into helping patients through these toxicities?

Dr. Andrew Epstein: And then finally, psychosocial care is going to be crucial to have improved models of delivery as the cancer patient population grows. And given the ongoing workforce shortages of specialty palliative care, we need to further investigate models of how we have excellent palliative care delivered from not only specialty palliative care, but also from the primary oncology teams themselves. And there's really important fascinating work going on in that space as well, encompassing not only symptom control, but also exploration of values and then finally, prognostic understanding and illness and treatment understanding that patients and families need to be helped through it by clinicians every day during their cancer journey.

ASCO Daily News: Absolutely. It's such an important field. My guest has been Dr. Andrew Epstein. Thank you for being on our podcast today.

Dr. Andrew Epstein: Thank you for having me. It was my pleasure.

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