ASCO Education

In this episode, moderated by Dr. Alissa Thomas (University of Vermont), patient caregiver Ms. Sandra Klima, hospice and palliative medicine physicians Dr. Gregg VandeKieft (Providence Institute for Human Caring) and Dr. Frank Ferris (Ohio Health), and medical oncologist Dr. Charles Blanke (Oregon Health and Science University) exchange perspectives on medical aid in dying, including legal, ethical and practical aspects. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org.   TRANSCRIPT Dr. Thomas: Hello, and welcome to the ASCO Education podcast series. My name is Dr. Thomas, and I'm a Neuro-oncologist at the University of Vermont Medical Center, and  Associate Professor in the College of Medicine in the Department of Neurological Sciences in Burlington, Vermont. As today's host, I will be moderating a discussion on medical aid in dying with four guest speakers, Dr. Gregg VandeKieft, who is a Palliative Care Physician, Clinical Ethicist and Executive Medical Director at Providence Institute for Human Caring in Olympia, Washington. Dr. Charles Blanke, a Medical Oncologist and Professor of Medicine at Oregon and Health Sciences University in Portland, Oregon. Sandra Klima, who is the partner and caregiver of a patient who passed away using medical aid in dying in Vermont. And Dr. Frank Ferris, who is a hospice and palliative medicine physician, as well as executive director of Palliative Medicine Research and Education at Ohio Health in Columbus, Ohio.     For consistency during this talk, we'll be using the term medical aid in dying or MAID to refer to death with dignity and physician-assisted dying. So, to begin the discussion, I'd love to hear from Sandra about your perspective as a caregiver. Can you share with us what it was like caring for your partner and what your reaction was when you learned about his wishes?  Sandra Klima: Yes. Thank you. I'm glad to participate. My partner had died of glioblastoma in April of 2018. When we found out, it was pretty shocking. The very first thing he brought up was Act 39. And initially I was very surprised and uncomfortable with it because I didn't want to think about death, I wanted to think about living. And he was very quick, Rob was very quick. We made an appointment at the funeral parlor. He wanted to get everything taken care of quickly. So I was shocked that he wanted to use Act 39. I did not feel that it was, as I said, appropriate to talk about, but he explained he had a friend who had glioblastoma and she did not take that action.  And she kept a diary and he said it was very difficult to read. And he did not want to go through that process that she went through. He didn't want to lose who he was. He wanted to die as himself instead of a short time later as a lesser person. And wanted the choice, and Act 39 gave that to him. And I respected and supported his decision once we talked about it. Cancer is a progressive disease and there comes a time when you will not be in control. Facing that and knowing it only goes downhill is scary. So having the option that looked out before the end phase is a blessing, and it is death with dignity, and that's how it feels to me.  Dr. Thomas: Thank you so much for sharing that experience. This has been a hot topic and I'd love to hear from our panel, what are some of the common misconceptions around medical aid in dying, and how is this different from concepts like euthanasia or assisted suicide?  Dr. VandeKieft: Well, for starters in the United States, all the states that allow aid in dying require the person to self administer the agent. So it's not euthanasia where somebody else administers the lethal agent. Our neighbors to the north in Canada actually do allow voluntary euthanasia and about 90% of their aid in dying individuals do it by voluntary euthanasia as opposed to self-administration. Another misconception is that it is heavily targeting the most vulnerable and disenfranchised, when in fact data from Oregon and Washington really indicate that it's mostly the well-educated, economically privileged who tend to utilize the aid and dying acts. And so there's actually been some questions in recent years about equity in rural areas and for other people who have difficulty accessing aid in dying,  Dr. Blanke: I'd love to reinforce that point. So, the Oregon data suggests that 74% of participants have at least some college, and almost 99% actually have medical insurance, although getting the insurance company to actually pay for the drugs is a different issue. I'd like to also suggest that opponents of death with dignity say that it violates the Hippocratic Oath, which I do not believe it does. Death with dignity deaths make up a tiny minority of overall deaths in any of the states where it is legal, and a good chunk of patients, somewhere between 30% and 60%, get the prescription and never even take it. So, I like to say that the act fights out of its weight class. A lot of people get the power and control of having that medication, but never actually need it.  Dr. Thomas: I understand there are a number of safeguards within the law to try to protect patients and help access and protect physicians. Would you be able to touch on the safeguards?  Dr. Blanke: I'll start there if okay, and most of the other states have modeled their law after Oregon's. So first the patient has to make multiple requests over time. They have to demonstrate a continued interest in death with dignity, and the law has built in cooling off periods. The patients have to clearly understand what will happen if they actually take these drugs, and what happens in 99.5% of cases is they will die as a result. The patients have to put in a witnessed written request for medications, and one of the witnesses cannot be related by blood or marriage, cannot be the patient's doctor, and most importantly can't be in a patient's will. They cannot have a financial interest in the death. So I think those are very reasonable patient safeguards.  Dr. VandeKieft: One exception I would call out is the state of Montana, which did not actually pass the legislation or a voter initiative to legalize aid in dying. But it was a state Supreme Court decision that said it was unconstitutional to prohibit it. So they actually don't have a regulatory framework in place, but they do offer protections to physicians. If they participate, they cannot be prosecuted. But all the other states in the US that have laws have a regulatory framework, much like Dr. Blanke just described.  Dr. Thomas: That's really helpful for the legal ramifications. What are the main ethical considerations around medical aid in dying?  Dr. VandeKieft: If you think of the classic ethical framework, autonomy tends to drive a lot of the conversation, that is the patient's right to self-determination. If they choose to pursue aid in dying, even if we morally disagree with the appropriateness of it, is it our position to prohibit them from following through with it? But then many others will also look at the concepts of beneficence, that is the obligation to do good for our patients, and non-maleficence, that is the obligation to not do harm for our patients. And people on both sides of the arguments will invoke those terms. People who oppose it would say the good is to prolong life. People who support it would say the good is to give people the right to choose the best quality of life and self-determination. People who oppose would say that the death, if it's self administered is actually a harm. The supporters would say the harm is making a person suffer, when in fact they have the potential to cut that suffering short on their own terms.  And so those ethics discussions tend to get into it fairly significantly, particularly around the public policy and social aspects. And then finally, at least within the health system I work, we've really shifted our focus away from a lot of the high-level legal and ethical debates and into what do you do for the patients who request it, and how do we make sure that there's non abandonment, accompaniment through the end of life, and that we seek out the reasons that they asked about aid in dying in the first place, and figure out how we can best serve the concerns that raised the question?  Dr. Blanke: I would love to actually strengthen that last point that Dr. V just brought up. A lot of patients use up three months of their expected six months survival barely finding me. Because what happens is they went to their primary provider, asked for death with dignity. Their physician says, "I don't do it. I don't know anybody who does. Good luck with it." This is a legal option in the state of Oregon, as well as about 11 other states. And the question as to whether or not providers have the obligation to at least refer, is a strong ethical point. A lot of the state's statutes say they can't hinder referral. They have to supply records if the patient asks for it, but I'm not aware that any of them have mandatory referral. And I think the physician is ethically obliged to offer that possibility, even if they don't want to write a prescription, which of course is totally okay.  Dr. Ferris: And if I might comment, I think the other obligation here is to, for the patient, particularly with cancer, but with anybody with any diagnosis who might be choosing this pathway is to ensure that they've had very early referral for palliative care services. That all their symptoms, any issues that are causing suffering are actually being addressed. And that as you have suggested, that they are clearly accompanied by somebody without bias, who understands how to unwrap and provide counseling in all the different realms psychological, social, spiritual counseling, to make sure that they and their families or their partners are in a really good place. Everybody's comfortable with the choice. The family lives on after a situation like this, and they need to have been comfortable with that. That the choice was the appropriate one for the person, and that what we're doing is we're respecting that person's choices and they're comfortable with it.  Dr. Blanke: I totally support that. The flip side of the coin is none of the states really say what to do if you are unable to offer death with dignity. They don't certainly mandate palliative care. I see a number of patients who really don't have terminal illnesses, or they have terminal illnesses that they are not expected to die within the mandatory six months. And I think we should ask ourselves, why are they seeking death with dignity? We have to ask ourselves, "Should we be referring these patients for psychiatric care?"  Dr. Ferris: Well, and if I could come back and emphasize that, I think oncology broadly has frequently had late referral patterns to palliative care services. I've got story after story, I'm a radiation oncologist by background, having done palliative care for the last 35 years. Even in the last couple of weeks, students learning with me have said, "We tried to get referrals and the oncologist wouldn't refer. Is there anything wrong with having a partnership?" So, the oncologist continues to do their wonderful work, at the same time we're managing the patient's experience and that people understand all their options, of which this is one of them, and they have a legal right to that in 11 states, so that we do the best possible care for people.  Dr. VandeKieft: I want to amplify your point. Dr. Ferris, if people choose aid in dying as the culmination of excellent palliative or end-of-life care, that's a very different scenario than if they're choosing it in lieu of palliative care because they don't have access. And so anybody who has access to aid in dying certainly should have access to the highest quality palliative care and hospice care and behavioral health, as Dr. Blanke pointed out, to make sure that they aren't despairing for something that could be treated more readily.  Dr. Ferris: And if I could add one more point, I think there's also a palliative care evangelist who says, "Well, if you just do this a little longer, everything's going to be wonderful." Except that we haven't made a difference. We as a community need to recognize when that's the case as well. So none of us are perfect, but it's the making sure we're a really comprehensive team and able to walk with people and honor and respect their choices.  Dr. Thomas: Thank you. We've spoken a lot about some of the logistics and legal and ethical aspects. I'd love to hear about what the experience is actually like. What are the barriers that patients face when they're trying to seek out medical aid in dying? We have a caregiver here who directly experienced this. How was it trying to access this and are their barriers either individually or systemically?  Sandra Klima: When Rob made his choice, we obviously had to go to the physicians and do the two interviews and get the approvals and wait the days in between and sign all the forms. But eventually we got to go pick up this medicine. But there was one pharmacy that had the medicine. We went, made a drive there. It was far from where we were. So we went over there. We had to plan it to be when there was a physician there who would give us the medicine. So that kind of struck me as strange. So you had to schedule everything and then you get there, and I don't know if it was my paranoia or what, but you feel like everyone's looking at you from behind the counter like, "Oh, you are the people coming to get that medicine?" And it was really just a little uncomfortable.  And you feel like you were almost doing something illegal. So that is the pressure I felt during that process about that. The only other piece is once you start this process in motion, we had the hospice people and the palliative care people contact us. We had several meetings with them. We talked about it with our cancer counselor, so I was very comfortable. And most importantly, Rob was comfortable to get the medicine that he would have to take and have it with him. It gave him peace of mind. It gave him freedom to enjoy his life.  Dr. Blanke: I'll add a few practical matters. The states that have death with dignity mandate that the patient takes it through their GI tract. That usually involves swallowing. We have a number of patients who are unable to swallow, or they have GI obstruction. They're allowed to take the medication through their rectum, although that eliminates a lot of the dignity from death with dignity. But we are not allowed to use intravenous formulations. Even if the patient self-administers. We also have patients and patients with Lou Gehrig's disease or amyotrophic lateral sclerosis make up about 11% of death with dignity users. Many of those patients do not have the use of their limbs. I had one young lady who was nearly completely paralyzed. She could move her head and she could move the pinky of one hand. And I spent somewhere north of four hours simply figuring out how she could fulfill the law by self administering a drug.  Finally we put in an NG and she was able to press a syringe plunger while I held a syringe, legal in Oregon, with that single pinky. I think the law is incredibly discriminatory against people with disabilities in the interest allegedly of protecting them. Next issue is we talked about the written request, which I do think offers safeguards, but sometimes it's hard. If patients want confidentiality, which the law allegedly is interested in, they may not want their neighbor to know that they're going to do this and they may not have somebody who is able to sign the form. Finally, we have talked a little bit about finding a participating provider. That continues to be an absolutely huge barrier, particularly because it's not just one provider, it's a prescribing physician and a consulting physician. They have to find two doctors, and if they're in say a Catholic health system or they're at the VA, sometimes it's nearly impossible for them.  Dr. VandeKieft: Loop back to Miss Klima’s comment about the peace of mind that her partner experienced, and note that sometimes even just the conversation provides that. I've had numerous patients who brought the topic up, and they weren't actually asking for requests. They were just seeking information or in one instance, trying to let her family know how badly she was suffering and bringing this up was a way of demonstrating that to them. But I had a patient with ALS who brought the question up. The fact that I accepted it, spoke back to her in a respectful and supportive manner, provided her some relief.  But then when the doctors from End of Life Washington, the advocacy group who can help provide support to people in the home, came out and visited her, she responded that it alleviated her anxiety and her depression, didn't resolve them, but eased them. And that also she learned that she didn't have to act as early as she thought she would have on her own. And so I kind of jokingly said, "So meeting with doctors may have actually prolonged your life." And she laughed and said, "You know, doctor, it did, because I would've done it earlier if I hadn't met with them."  Dr. Ferris: If I can speak to what you just said back in the era of HIV and AIDS, when we had very little, I cared for more than 1,000 people out in the community. And I would say more than 60% of them asked me that question of when they got to a spot of intractable suffering, when I hastened their death. And of course that was illegal in those days. But what I was clearly able to do, is talk about palliative sedation for them, to be clear I would look after them, clear I would look after their families. And just as you have suggested, I think one of the huge issues is, "I have an option. I have an alternative here. Somebody is going to look after me. And if I've decided, if I'm going to go to medical aid in dying, if I'm going to go the palliative route, I don't have to experience the horrible part that I don't want to experience."  We need to talk about both of these openly with people, and be clear that they and their families will be accompanied in whatever the process and as you've suggested, without judgment, maintaining confidentiality. These are super important issues for people. I think about my own personal future, these things loom. I think it is people with lots of thoughts about what might happen, maybe a bit too much knowledge, who worry about the intractable nature of suffering, whatever it is, whether it's psychological, physical, spiritual. It's being able to accompany people appropriately and respect their choices.  Dr. Thomas: Right.  Dr. Blanke: So I'd like to add one more practical detail. We talked a little bit about finding providers and how difficult that is. And if you think about the challenge of finding two providers in Portland, you have to multiply that by about 100 to find any providers in Klamath Falls or Eastern Oregon. The good news is telemedicine has made our lives and the lives of our patients quite a bit easier.  Dr. Thomas: As I listen to the conversation, I'd be curious about your thoughts about health equity issues around this. You've alluded to the fact that somebody who has physical or neurologic disability may have challenges depending on where you live. It may be challenging to access. Are there other populations of patients where you worry about health equity and access to medical aid in dying?  Dr. Blanke: Well, I can comment that most of the patients find me or my colleagues who provide this through web searches. So, they have to have access to computers, which is not necessarily all that easy for all the rural residents of Oregon. Even though I told you that 99% of patients have insurance, we also mentioned that getting the insurance company to pay for the drug is very, very difficult. Hospice almost never wants to pay for it for the usual hospice- related reasons, and the drugs are about $700 in Oregon. That is a hindrance to a lot of my patients.  Dr. VandeKieft: I think being mindful of historic disenfranchised communities, people of color, Native Americans, that the healthcare system has not always treated fairly historically, and they have reasons to be suspect at times. Now this is something that usually they will seek us out as opposed to the healthcare system promoting it, but just being sensitive to the fact that we're doing something that could be perceived as problematic by communities who have historically been mistreated by the health system as well as other systems.  Dr. Thomas: I'd like to just have a better understanding of residency and the law. I think that there is written into most of these laws, you have to be a resident of the state where medical aid in dying is available. But what does that mean to be a resident, and how do states define that?  Dr. Blanke: So for us in Oregon, it's not like the classic situation where you have to demonstrate that you have a driver's license or you have to produce a gas bill in your name. The statute basically allows the prescriber to define residency in their own mind.  Dr. Thomas: What advice would you give to oncologists and other physicians who might have patients approach with questions about this? How do you talk with patients about this matter?  Dr. VandeKieft: The very first thing I respond to is... This is a very important question. I appreciate that you brought it up and that you have the [inaudible 00:20:35] and trust in me to raise the topic. But before I get into the details, I'd like to learn more about what led you to ask me about it. Would that be okay? And even that last phrase, would that be okay as intentional and that by asking permission, I'm making sure that they have agency, and demonstrating respect to them. But that approach has made a huge difference in that I have learned on many occasions, people have no intent of actually proceeding with it. As I mentioned earlier, they may simply be asking for information.  One gentleman, his response was, "Well, my buddies told me about it, and I didn't even know that was a law. And when I started to explain it, he said, oh, that sounds too much like suicide. I would never do that. And then the other woman, I referenced, she went through it and then looked at me and said, “Doctor, I would never do it.”, and looked at her daughter and son-in-law, “I just want my family to know how badly I'm suffering.” And so starting with that open-ended question is really crucial because if we make assumptions and if we start projecting our own biases onto them, we may completely miss what they're looking for and the opportunity to provide them the best services that we could.  Dr. Blanke: If I merely mention that this is an option, the patient is going to think that I'm recommending it, and I certainly don't see it that way. It's just one of many options. If we offer chemotherapy, we are not mandating that particular drug or even suggesting they get chemotherapy at all. Certainly, with the exception of palliative care, I recommend they seek that out, that I really want them to seek it out. But I think it's incumbent on the providers if they see a patient with a terminal illness to list this among the many options that are possible for the patient living in Oregon or those other 10 states. I know that's controversial.  Dr. Ferris: Well, I really want to highlight what you just said, Gregg, about the process of inquiry. To me, everybody practicing oncology, everybody practicing medicine needs to be able to model exactly the way you opened when asking any significant question, including prognosis, "When am I going to die? What about this therapy?" Because what we know, many of the times, patients aren't asking what the words specifically say, they're calling out their suffering and how can we help them? Or they've got a plan, they've got something they want to do. So that was beautiful modeling, Gregg.  Dr. VandeKieft: Dr. Blanke, he used that example of people not hearing. And one of the cases that I still struggle with a little bit, I work in a Catholic health system, so I'm not a participating physician. And we're really counseled that we shouldn't be the one to bring it up. And I had an elderly woman. I was doing a hospice home visit and she asked me how long I thought she had. And unfortunately, Dr. Ferris, I didn't think to ask her what led her to ask me the question on that occasion. And I probably should have, because I told her my prognosis and she looked at me with a profound look of disappointment and said, "I don't think I can suffer that much longer." And a couple of days later, she died very unexpectedly. She took an intentional overdose and the fact that I didn't inform her of the option of aid in dying still haunts me that I may have failed her.  Dr. Thomas: Thank you so much for sharing that. Ms. Klima, we've heard a lot from the experts. Is there advice you'd give patient to patient or caregiver to caregiver about what to ask your physicians?  Sandra Klima: You need to ask as many questions as you want and have the doctor answer you truthfully. I think when a patient is asking a doctor a question, they're asking the doctor, "What are my options?" I'm going to assume you're going to give me all the options. I'm not going to assume you're not going to tell me the options you don't like, because I want to know what are my options. I'm the one who's suffering. I'm the one who will have to make a choice. And I can tell you the choice Rob made, to use Act 39 in Vermont, was a blessing for us. It was a peaceful death that I cannot overemphasize. It was the right decision to make. It was for his decision, but it was the right decision to make.  And I think if a physician would not have told us of that option, I would be in the same situation that you felt, Gregg, where the lady took it upon herself. Because you thought through it, you had a plan, it was planned. It was a nice wind up to an ending. And I think that physicians owe it to their patients to tell them all of the options available and let the patient make a choice. I also think physicians owe it to the patient to be clear what the end phase of their life will be. Because it's not roses. If they don't do this, they have to live through that end phase, which sometimes it's horrific. And I think they need to have a clear understanding of what's to come and a clean list of all the options. And I think that should just be required, and personal choice of a physician is not on the table.  Dr. Ferris: So it's important that we explain all the options, I completely agree, that are available within the context of the law. And certainly in the Americas, in Europe, and I've been in many other countries where palliative sedation is one of those therapeutic options. Where the patients can have amnesia, the family can be well looked after. We need to describe all the available options that are within the law, in the jurisdiction in which we live. I completely agree.  Dr. Blanke: And I'll add that that actually also applies to some of the patients who want death with dignity, are suffering horribly but don't actually qualify because they have a chronic illness expected to live too long. I just saw a patient last week and we actually talked about VCED, the voluntary cessation of eating and drinking, which is something that many, many people fear, including providers, but if done properly is fantastic. She used VCED. She passed away. She died two days later and her family could not have been more thankful.  Sandra Klima: I'll chime in on that because the comparison between my father dying and Rob dying, it really just has an impression on my mind. My father did not have a diagnosis of X amount of months to live, but my father had chronic problems and he was suffering. And the death that I watched him go through and was with him for, was nothing like Rob's death. It wasn't peaceful. It haunts me today. It haunts me. My father should have been a candidate, but he wasn't. What was the point of living four more months in this miserable state?  Dr. Thomas: You know, it dawns on me that this is a very different kind of death. It is not suicide legally or medically. It's a different process than natural death from a terminal illness. And it's not even possible in every state or every country. And I imagine it is very different for the people who are left behind, for family members and caregivers to process this kind of death and bereavement after their loved one passes. Can you comment, Sandra, on how medical aid in dying affects the caregivers and affects the family and how you can prepare for bereavement and support in bereavement?  Sandra Klima: I felt that this death was anticipated, and my bereavement, the part that bothered me about Rob's end of life, was that I was unprepared for how quickly the decision was made. The decision was made quickly because he started getting paralyzed again on the side of his body. And he decided, "Today's the day." And it was three or four hours later, and it took me by surprise at how quickly the decision was going to be made. That's the only part I regret was I didn't have a strong enough plan about what was going to happen when that decision was made. That probably needs to be emphasized because you can plan all you want when it's not going to happen. But at the moment it happens, it's like a fire drill. You got to go through and get all those things lined up. And I can tell you, I felt worse for my father's death than I did for Rob's death. So even though it's a different kind of death, it was a peaceful death with dignity.  Dr. Blanke: In terms of the bereavement, I have seen all sorts of responses from patients' families initially, from those who could not be more supportive. Sometimes they even seem to want it more than the patient does, to those who actively oppose it. But in my experience, which now numbers about 205, the families are almost always on board at the end when they see how much the patient has been suffering and how much peace the actual control over the patient's life and death gives them. I always offer after the patient is gone to the family to contact me whether it's a week later or a month later, or a year later, if they have questions about the process, if they need any help in referrals. It's never happened a single time.  Dr. VandeKieft: I think back to the landmark article that Tim Quill published in the early 1990s about his patient, Diane, and how he highlighted that she ended up committing suicide. And there's kind of a shame, it's done in the shadows, and that when you have aid in dying as an option that can be brought out into a planned open manner in the way that Ms Klima is describing with her partner. And then also with the bereavement and the partners, I think we need to listen once again. I just had a case yesterday that somebody was telling me of a gentleman who got the prescription for aid in dying, but ended up not taking it and died of "natural causes."  His wife told the bereavement counselor afterwards, “That was such a relief because I was struggling terribly with the spiritual aspects of this. And I would've really had a hard time had he gone through with it.” She had not shared that with her husband or anyone else because she wanted to be so supportive of him. And it was only by the bereavement counselor, listening and opening up that she could really understand, "What are the true struggles that this family is going through and how can I meet their needs?"  Dr. Ferris: If I can comment, it doesn't matter whether people have chosen medical aid in dying. When people die, there's a loss for anybody who's a survivor. People can be comfortable with the process that occurred or not. They can perceive suffering or not. The loss leads to changes. And what we know is the transitions through the loss period that we call bereavement for different people are profound in different ways. And what we need to make sure is that people are connected with services. It's why with every patient I care for, whatever therapy provided, I do participate in ventilator withdrawal. I participate in palliative sedation. I've done this all my career. I make sure they're in the hospice system, in the United States, which provides people with 13 months bereavement support or more, because if a death occurs in a hospital without hospice care, then the patient gets a decedent phone call from the chaplain, if they're lucky, or they're lucky enough to have a physician like Dr. Blanke who says call me.  Most people don't make themselves available and you're out at sea. And we know that the suffering of a bereavement can lead to incapacitance, people depressed, not functional, people even get illnesses in the process. So there's a huge cost to society for not addressing this issue carefully. It's about the preparation, and what I try to do is get the bereavement conversation going before the person dies, so that we're talking about it and integrating it.  Sandra Klima: Right, I agree.  Dr. Thomas: Thank you all so much for this conversation. Thank you, Sandra Klima and Dr. VandeKieft and Dr. Blanke and Dr. Ferris. I think this was such an important conversation. Talking about death can be very difficult and I just appreciate the openness and sensitivity and your willingness to share these experiences. Thank you to all of our listeners. We appreciate you tuning into this episode of ASCO Education podcast.    Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive education center at education.asco.org.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional 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. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization activity or therapy should not be construed as an ASCO endorsement. 

Drs. David Johnson (University of Texas) and Patrick Loehrer (Indiana University) host the first of two Oncology, Etc. episodes featuring Mr. Paul Goldberg, book author, investigative reporter, and Editor and Publisher of The Cancer Letter. In part one, Mr. Goldberg reflects on his two main interests − human rights and cancer, and his early career as a journalist and novelist. If you liked this episode, please subscribe. Learn more at education.asco.org, or email us at education@asco.org.   TRANSCRIPT Dr. Pat Loehrer: Hi I’m Pat Loehrer, I'm the director of the Center for Global Oncology and Health Equity here at Indiana University. Dr. David Johnson: Hello, my name is David Johnson. I'm at UT Southwestern in Dallas, Texas. And we've got a great guest today and we’re excited about the interview. Dr. Pat Loehrer: Yeah, it's very timely too, I think it's terrific. Before we go on to that, are there any recent books that you've read that you want to recommend? Dr. David Johnson: Yeah, actually, I do. It's somewhat related to our topic today. I just finished a book entitled, Presumed Guilty by Erwin Chemerinsky, who's the Dean of the Law School at the University of California, Berkeley. It's actually recommended to me by a lawyer friend. I think most of our audience knows the fourth, fifth, and sixth amendments to the Constitution are the ones that provide protection for people accused of crimes. And I think most of us are familiar with the Warren Court in the 50s and 60s, which seemed to be a very, quote-unquote liberal court that provided many of the protections that you see on TV shows, police TV shows de including the Miranda protections, but as Chemerinsky points out in his book, that really is a historical aberration, that the Supreme Court from its founding really right through today is then on the opposite side of the fence in terms of protection to the accused can many landmark rulings over the last several years, including Terry versus Ohio and City of Los Angeles vs. Ryan, have actually provided protection and sanction stop in frisk activities, limited suits against police departments to institute reform, and even provided some benefit for the use of so-called lethal chokeholds. Smaller than I think, in light of what's happened over the last several months, really provided some insight, to me at least, about how the Supreme Court looks at the protection of the accused. I thought it was a very interesting book to read. And Chemerinsky does a great job of explaining these landmark cases in a way that simpleton like myself can understand them. So, I recommend it to you. I think you'd enjoy it. Dr. Pat Loehrer: Yeah, there’s a book called “Just Mercy” by Bryan Stevenson. I'm not sure if you've ever had a chance to read that. It is an outstanding read. They made a movie out of it but if you get a chance to read the book, it's really terrific. Again, it talks a lot about the inequities in terms of how our court systems have prosecuted people of color for minor crimes compared to people that are in the majority here. But I think both of those would be great reads. Dr. David Johnson: Yeah, I haven't read it, but I will. Dr. Pat Loehrer: Yeah, it's terrific. Go for it. Going ahead in getting started, it's our great pleasure to have Mr. Paul Goldberg join us today. Anyone in oncology knows him. He is the editor of the Cancer Letter. Interestingly, he was born in Moscow and emigrated here to the United States at the age of 14, where he went to Virginia. He got his undergraduate degree at Duke in economics. And shortly thereafter, he worked in a newspaper in Reston, Virginia, where he met his future wife. I think from there, they went to the Wichita Eagle in Kansas. His wife was actually the daughter of the founder of what was to become the Cancer Letter, Jerry Boyd. He rose to associate editor and finally editor in 1994, and publisher and editor about a decade ago. The Cancer Letter is the go-to newspaper for us in oncology. Over 200 institutions subscribe. There's not a cancer center director in the country that does not look forward every week. One is to see if it's in there, you hope it isn't. And then if it is, you hope that there are really some platitudes in there about how wonderful you are, and then you can go ahead and read the rest of the article. The New York Times once said that everybody who's anybody in the cancer field reads this newsletter. He's won a number of awards, including the Washington DC professional chapter of the Society of Professional Dermatologists and some Gerald Loeb awards. His investigative work has uncovered some extraordinary events, including the Duke scandal with genomics, the ImClone scandal, as well as some of the workings of SIPRAD and MD Anderson, and I think he is really a flashlight that looks in the dark corners of our world, but also is there also to cheer on some of the accomplishments in oncology, and he knows Brawley and have written a book together, How We Do Harm. They're also doing the history of oncology together. He's a novelist. He's a nonfiction writer, and he's an extraordinary individual. And I think we're really looking forward to spending a few minutes with you here, Paul, thank you for joining us. Paul Goldberg: Thank you for inviting me. This is really a pleasure to spend some time with friends. Dr. Pat Loehrer: Well, by the time this gets aired, hopefully, the crisis in Ukraine will be over. But just last week, the Russians invaded Ukraine, and I think it's very timely to hear more about this and the fact that you grew up in Moscow and Russia. Tell us a little bit about your early life, your upbringing, your family background, and what prompted your family to immigrate here to the United States? Paul Goldberg: Well, it suddenly became possible and it was something that my father wanted to do. So, we just sort of ran as soon as we could, and certainly, I had kind of a fascinating time that I've been chewing on for many years as a novelist. In fact, they've just turned it into a novel, which will be published not this coming summer, but the following summer, it's called The Dissident. It's about the Soviet human rights movement and it's set in 1976. By then I was here, actually. But it's kind of like material that found me and really weirdly, it's also why I’m in oncology, where I'm covering oncology. My material kind of found me when I was in college, my drinking friend’s mother, Ludmila Alexeiava was one of the founders of the Moscow Helsinki group. Interestingly, also, my first book was about the Moscow Helsinki watch group, which is really the beginning of human rights monitoring, which is really a staple, let's say the beginning of the NGOs. It's a staple of world order to rely on people within the country that it’s being written about covering themselves in a way. It's kind of like free social media. And then, of course, enhanced greatly by social media. That was my beginning, but what was also interesting is that being a writer, and I really wanted to be a novelist, I did not want to then write nonfiction, but the material was so good that I had to jump in. Then I also had to, like, temporarily at least, make a living doing something else. So, my former father-in-law, my dad at the time, my father-in-law, now my late former father-in-law, terrific guy, Jerry Boyd, just hired me to do some work for him. I started some stuff and he used to brag that he's the only guy who's ever made money off son-in-law. Dr. David Johnson: But Paul, I'd be really interested to know, where did your interest in cancer begin? Was it with the Cancer Letter or had there been some interest prior to that? Paul Goldberg: Well, when I was working for the Wichita Eagle, I kind of got interested, I always gravitated towards stories about things like insurance, for example, the value of life, anything that had to do with these sorts of very complicated philosophical questions. That was kind of the beginning of my interest. That's why I didn't say, oh, no, this is too wonky. I don't want to have anything to do with this. Also, when people realize, it’s always interesting, there's a fair amount of that in oncology. So, I was trying to find that, and just the complexity and the characters. You'll run into characters in oncology that you kind of wish to run into because you can have half an hour-long conversations or two-hour-long conversations or three-hour-long conversations with a lot of folks without really getting off-topic. I mean, I get a lot of criticism from the kids and my staff telling me that I'm nonlinear in my thinking, but that's linear in this field. It's also once you get into questions like ethics, that's really the fundamentals of oncology, and that's also the fundamentals of my other interest, which is human rights. It's also the artistic potential of this field is incredible. It just kind of grew on me but basically, it all began as a kind of a way to make up for unevenness in cash flow from writing books. And then it just became so great. If you want, I can tell you what the actual events were that made me just say, this is my field. Dr. David Johnson: Yeah, I'd love to hear that, tell us. Paul Goldberg: Two early ones. One of them was the beginning of the National Breast Cancer Coalition. I was initially taking a nap at the Senate hearing. I was editing a manuscript that was around 1992. I was editing a manuscript that got a little bit boring for me to just sort of listen to most things and I just fell asleep. And then I heard Fran Visco’s voice booming through and I had no idea who Fran Visco was, nobody had any idea who Fran Visco was. He was giving her “Men in Suits” speech, which is like the beginning of the patient's movement in breast cancer. I kind of woke up and I pushed the button on my tape recorder and I got it. It was just unbelievably cool. I said, okay, so conversations that they had in the kitchens, wherever, there are these people who are talking about setting up a public movement, because there was never a public movement really of patients in oncology. For the most part, it just felt a little bit boring. I started working around the corners of oncology around 1985-86, really, 5 or 6 years later, I was writing other books. And I was bored a little bit because there were a bunch of white guys making decisions behind closed doors. They stopped smoking a few years before, but there were still white guys behind closed doors. Suddenly, this was something completely different. This was a public movement. And I could recognize the public movement because I'd seen them, I'd written about them, I did a story about them. So, there was that. Then came up about that very same time, really roughly the same time came the NSABP scandal. The Cancer Letter was writing fairly short stories. Now, it has been around since 1973. So, there's just this incredibly rigorous device for monitoring the history of oncology, you can just crack the thing. But it was different because Jerry didn't write 5000-word stories. Sometimes he did but mostly he didn’t. But I can't really express myself briefly, I kind of have to go, and so, I started realizing that I could just return to this story over and over and over till I understood it, until everybody else got, so because of drilling, probably I must have written 40 stories on NSABP, maybe more. I don't know, over the years, maybe I'd written, but they just sort of said to me, hey, this is a field that's now politicized in a way that kind of sustains journalism. Controversy is unbelievably cool with this because here's a group of patients who are saying, we don't really care about NIH funding, in this case, but we care about just funding for breast cancer, and we want to do it our way. Let's do it through DOD. That was an amazing story to cover. Then there's the story of Bernie Fisher, who was like the great man of oncology, getting kind of pulled through the wringer on this thing, and it was awesome. Then another thing started happening. I started going to the meetings, mostly I loved ODAC. I always loved ODAC and I still love ODAC. I haven't missed an ODAC for maybe 40 years or something. And the same goes of course, for NCAB.  Basically, here is a discussion as a spectator sport. Oh, wow! I kind of got passionate about this whole thing. Like, covering ODAC like Dave Johnson's ODAC was hilarious. It was a comedy show. Basically, Dave was doing some really cool stuff. Really good material, not really quotable because the jokes were a little loud. Schilsky was hilarious in the ODAC. Raghavan was really funny on ODAC. And then there was Sledge. It was also very, very funny.  So, there was this sort of a discussion of this very complicated stuff that I just started quoting. I think I must have quoted Dave's joke. I think you learned from your grandfather, a box turtle on top of a fencepost didn't get there by accident.  Dr. David Johnson: It's correct.  Paul Goldberg: Yeah, it became an obsession to just follow the characters.  Dr. Pat Loehrer: But by the way, Paul, we did interview Rick Pazdur a short time ago, and Rick did not say that Dave was funny. I just want to let you know. There was no comment about that at all. So, there's just another side to this story.  Paul Goldberg: Well, the funniest bit was when Derek Raghavan once asked, we need a translator here for southern English, why does it need a box turtle on a fence and it gets there by accident? I don't think Dave explained that that time, but I have to look at my story because I would just get into these digressions of this. I think that was also where Rich Schilsky invented the term, toxic placebo.  Dr. David Johnson: Yes, we had a study, we had to review that showed, frankly, that the placebo was actually better in some ways than the actual alleged, like the drug but with a lot of side effects.  So, Paul, you've been in the midst of a lot of really interesting stories, some would say controversial ones. ImClone, Pat mentioned earlier, the Duke scandal, where do you get your information? Without divulging.  Paul Goldberg: Well, some of them I can't really divulge. But some of them I can. The beauty of the internet now is that people can come up with an email address and send me stuff and I can actually communicate with them, and I don't even have to protect my source because I have no idea who my source is.  There was one of these stories you've mentioned, I'm not going to say which one where I could just sort of dial in the question. Like, I could just email this person whose nickname could be Mickey Mouse. I mean, I think that was Mickey Mouse. So, I can just send the question to Mickey Mouse, what happened at XYZ? I'd like to see a picture of XYZ, and then Mickey Mouse would send me something.  Dr. Pat Loehrer: This is like all the president's men?  Paul Goldberg: It's a lot like that. It's much easier because you don't have to count back or whatever and hang up, although I've done that it's kind of funny. Yeah, sometimes things show up anonymously.  Dr. Pat Loehrer: Well, that concludes part one of our intriguing interview with the cancer letter Editor Paul Goldberg. Stay tuned for part two of this conversation, where we'll learn more about the literary works of Mr. Goldberg, who's developed these works outside of the Cancer Letter.  We’ll see and hear about his incredibly important insight into the Russian Ukrainian conflict and much more. Thank you to all our listeners for tuning into Oncology, Etc. This is an ASCO education podcast where we will talk just about anything and everything. If you have an idea for a topic or a guest you'd like to see on the show, please email us at education@asco.org.    Thank you for listening to the ASCO education podcast. To stay up to date with the latest episodes. Please click subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive education center at education that asco.org.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional 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. Guest statements on the podcast do not express the opinions of ASCO the mention of any product service organization activity or therapy should not be construed as an ASCO endorsement. 

In the second of our two-part interview, Oncology, Etc. hosts Drs. Patrick Loehrer (Indiana University) and David Johnson (University of Texas) continue their conversation with two physician astronauts. Hear the incredible stories of Drs. Robert L. Satcher (MD Anderson), Ellen Baker (MD Anderson), and their lives on and off this planet. If you liked this episode, please subscribe. Learn more at education.asco.org, or email us at education@asco.org.   TRANSCRIPT David Johnson (Dave): I'm Dave Johnson at UT Southwestern Medical Center in Dallas, Texas. I'm here with Pat Loehrer, my good friend who also happens to be the Director of Global oncology and Health Equity at Indiana University. Welcome back to Oncology, Etc. And part two of our conversation with Dr. Ellen Baker and Dr. Robert Satcher. Dr. Baker and Satcher are former NASA astronauts now practicing in Indiana Cancer Center in Houston. In Episode One, we learned about their time at NASA and some of their spaceflight adventures. In this episode, we will learn more about their post-NASA activities. We will rejoin the conversation with Pat asking Dr. Baker, how her work in space informed what she does now. Patrick Loehrer (Pat): I know Ellen, you do work with Project ECHO, which is doing work globally. Tell us a little bit about that if you could. Ellen Baker: You know NASA seems a million lenses away now. I sort of vaguely remember my flights which were a long time ago, more than 25 years now, but seems like yesterday. But you learn a set of skills that are transferable, I think. You come into NASA with some skills that are transferable and you leave with those. We did a lot of work with international partners, particularly in the 90s with the Russians. And I now do a lot of work with international colleagues, particularly in Africa, Central, and South America. I think that's one of my transferable skills, perhaps from NASA. And I don't know, Bobby, it's thinking on your feet and being adaptable and not getting flustered and compartmentalizing, and quite honestly, a lot of those are skills I think you develop in medicine as well. So, there are a lot of similarities and I think a lot of benefits flow in both directions. Dave: Could you elaborate a little bit on Project ECHO that you're involved in? What sorts of things are you doing with Project Echo? Ellen Baker: Project ECHO is very simple, it's a video conference where you connect specialists generally at academic institutions with medical providers in rural and underserved communities where perhaps specialists are not available. And the intent is to meet on a regular basis and provide assistance and support and patient care. So, providers in isolated or rural communities or underserved communities can care for their patients locally and patients then don't have to be referred to a tertiary care center, often very far away at great cost, etc. It was designed by a gastroenterologist at The University of New Mexico, Sanjeev Arora, who started the ECHO program, it stands for “Extension for Community Health Care Outcomes. In New Mexico, it was at a university in Albuquerque, there were maybe 30,000 patients around New Mexico who had hepatitis C, and were not being treated except perhaps in his clinic. And he partnered with about 21 providers in the community around the state and gave them the support they needed to be able to provide care for patients with hepatitis C, locally. This was back when the treatment was quite toxic. A lot of primary care providers didn't feel comfortable delivering this sort of care. That was sort of the beginning of ECHO, and it's since been applied to many different disciplines. At MD Anderson, we have, I don't know, I think maybe 13 Different ECHO programs for cancer prevention. That would be cervical cancer prevention, tobacco treatment, melanoma detection, also for treatment, primarily with partners who are international. We worked a lot with partners in Mozambique for the treatment of chronological cancers, breast cancers, and hematologic cancers, survivorship, palliative care, and even health care policy. So, that's sort of the ECHO in a nutshell, and we use it quite a bit at MD Anderson, but we're just one of the hundreds of different institutions that use the ECHO model for this. Pat: What I get from you, Ellen, though, is a sense of telemedicine and teamwork and collaboration, which is a lesson that you have to have, I think, as an astronaut to be able to do that. And Dr. Satcher, your extent and your thoughts now, how has that experience as an astronaut informed your current work? Robert Satcher: A lot of the skills are transferable. You come in with skills like medical training that you use and build upon when you become an astronaut. And then once you leave If you come back to the medical profession, there are a lot of skills that transferred to that field too. I see what I do is surgery, it's sort of an activity, which has a beginning and an end similar to spaceflight. And operationally, a lot of the skills that we learned as astronauts actually do transfer very well to doing surgeries. Now, one of the things that were more recently brought over is just the whole idea of a pre-brief and a debrief, which we do for surgeries now and that wasn't the case when I was training back in medical school. So, it’s sort of a recent adaptation. But while I was at NASA, I would often think about that. Now, this actually would work really well, when doing surgeries, because it would help improve the process and actually make sure that you're making the best use of resources, people, etc, which they do a very good job of training you as an astronaut. The telemedicine aspect of being an astronaut and taking care of people that way, we finally are doing that at MD Anderson, reluctant adapters in the cancer world to using technology sometimes like that, although in the ER, we use a lot of technology, I think there's still this notion that there needs to be a real face to face connection between doctor and patient, very strongly rooted in the cancer world, for obvious reasons, in the past, being diagnosed with cancer, and certain types of cancer, certainly, was just amounted to a death sentence, because there weren't good ways of taking care of people. But now with advances and what we've been able to do, the outlook for cancer patients is much better now than it's ever been and continuously improving. And the pandemic is really the thing that forced this change in the cancer world and I was actually part of the effort introducing video visits at MD Anderson, which is part of something that it's going to be doing moving forward. Fortunately, the advantages of it are kind of obvious. You don't have to come into the institution for everything. It basically allows continuity of care and it potentially allows you to reach more people. That's something that makes cancer care more equitable, which is something that needs to happen similar to how becoming an astronaut needed to be more equitable. So, a lot of these kinds of things do carry over. The other aspect of training at NASA, which I think I can relate a lot to, was actually when I did the spacewalks and being focused on getting some specific tasks done. It felt the most like doing surgery and we were actually doing some repairs on the robotic arm because it was very technical, using these specialized instruments and having to be very careful. Dave: How do you keep from spinning off in space by using one of those ratchet tools? Like they put tires on NASA? Do you have to use something like that? Robert Satcher: Well, they thought of all of these things, of course. You have all of the foot restraints, other ways of stabilizing yourself. The foot restraint is one of the main ways you also have a restraint that's sort of like a, how do you describe it, it's like… Pat: A tether? Robert Satcher: There's the tether to keep you from floating away. But it's a restraint that's mounted on your belt, essentially. And it’s sort of a screw mechanism that makes it flexible, then you can attach it to a rail or whatnot. And then you rigidize it by screwing in the opposite direction, which is a very clever device but it helps you to keep from spinning as you say. Dave: So, both of you have really gotten into global health in your own separate ways, I suppose. And maybe this seems obvious, but did your experiences looking back at Earth have any influence, or were you interested long before you began your NASA careers? Maybe we should start with Ellen. Ellen Baker: I think I was interested before my NASA career. I was actually one of the only members of my medical school class who did a rotation abroad, back when almost nobody did rotations abroad as a fourth-year med student, and I like to say, well, I kind of got distracted by this NASA thing. And after I finished with that, I came back to medicine and sort of rekindled my interest in global health. Dave: And Robert, what about you? Robert Satcher: Yeah, I did too. We traveled. When I was growing up, we spent six months in Uganda. That piqued my interest in traveling and then when I was in medical school, the rotation in Gabon as part of the Schweitzer fellowship, and then when I was in residency too, I did several trips and a couple of attendings in orthopedic surgery when I was doing these trips to South America. And that's when I did those, and, in fact, continued when I was a faculty member at Northwestern, doing some additional trips to under-resourced countries. So, that's been sort of my interest. Pat: Thank you for your work. It's incredible. We have a couple of questions. I wanted to talk for another couple of hours, but we weren't able to do that. Dave and I talked about books. What I do want to know from you is what is your favorite movie about space that you think is the most accurate one and maybe perhaps the best book or any other recent book that you've read? How about you first, Robie? Robert Satcher: I don’t get any answer for the book because I haven't read a lot of Space books, but for the movie. 2001 Stanley Kubrick. Dave: Absolutely. Robert Satcher: At the time, they did that really well. And that was before I became an astronaut. When I go back and look at it now. I still think, yeah, just very intelligent. Obviously, it's a very thrilling movie too. Pat: I'm not saying that I'm old, but I remember in high school and grade school reading 1984 as a futuristic novel, and 2001 came out as futuristic and now it just blows your way that it's 40 and 50 years ago, that happened. Ellen, how about you? Ellen Baker: I have to say there are a lot of space movies out there that I don't like. I'm not a fan of space movies, where there are vehicles exploding and getting lost, and I find it a little bit offensive when the laws of physics are ignored. So, I would say there are some really good documentaries out there. And the real thing, I think, is at least as exciting as Hollywood. So, there are a couple of really good documentaries that are actually current right now. And in terms of Hollywood, I would say the Martian was pretty good and it was a bit classic in the astronaut office. I think they did try to obey most of the laws of physics. And there were one or two folks in the astronaut office who we thought could definitely be the Martian. Pat: That's a great book. It has the best opening line of any book ever written, which I am not going to repeat here, but if you're curious about it, pick up the book and just read that first line there, it says it all. Dave: Another question, we'd like to ask our guests, and we'll start this time with you, Ellen. If you could speak to your younger self, knowing what you know today, what advice would you give yourself at the beginning of your medical career that you didn't know then but you know now? Ellen Baker: I think when you're 25, you think you have all the time in the world. And as I got older, there was so much more I wanted to do in medicine and perhaps I would have focused a little bit more, and I wasted a lot of time. I had a lot of fun. But what seems the older I get, the more I've got to cram into the time that I have left. And maybe that's just life, that would be it, I think. Dave: I think that's an important point. I often tell residents and my colleagues that you can lose a lot of things and regain them, but you can't lose time and regain it. So, use it wisely. Robert, what would you tell your younger self? Rober Satcher: I'd probably say there's no such thing really as perfection that that shouldn't be something that you obsess with. Over the years, I've learned that and I saw an article recently about a surgeon talking about good enough is good enough and the enemy of good is better. I think that has a lot of practical ramifications in terms of how one should wisely spend their time. So, I would emphasize that to my younger self. Dave: So, thank you for that. I think both bits of advice are very helpful. Well, that's really all the time we have for today. We could go on, I'm sure for several more hours. I want to thank both Dr. Baker and Dr. Satcher for their participation in an incredible conversation. I also want to thank our listeners for tuning in on Oncology, Etc. This is an ASCO educational podcast where we'll talk just about anything. If you have an idea for a topic or a guest, please send us an email at asco.org. Pat, before we sign off, do you know why an astronaut would be a good spokesperson for the COVID vaccine? Pat: No, I don't, Dave. Dave: Come on! You got to know that they like booster shots. Pat: That's good. Dave: Alright guys, thanks a lot.   Thank you for listening to the ASCO education podcast. To stay up to date with the latest episodes. Please click subscribe bribe? Let us know what you think by leaving a review. For more information, visit the comprehensive education center at education that asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional 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. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product service organization, activity, or therapy should not be construed as an ESCO endorsement.

In the second of this two-part ASCO Education Podcast episode, Drs. Stephen Berns (University of Vermont), Tyler Johnson (Stanford Medicine), and Katie Stowers (Oregon Health & Science University) continue their discussion about what it takes to deliver serious news to people with cancer effectively and compassionately. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org.   TRANSCRIPT [MUSIC PLAYING]   STEVE BURNS: Hello, and welcome to the second part of ASCO's Education Podcast focused on clinician-patient communication in the context of delivering serious news to patients and families. My name is Steve Burns. I'm an internist, hospice, and palliative care physician and associate professor of medicine at the University of Vermont College of Medicine. Once again, I'm joined by Katie Stowers, a hospice and palliative care physician and assistant professor of medicine at the Oregon Health Science University, and Tyler Johnson, a medical oncologist and clinical assistant professor of medicine at Stanford University. In our previous episode, we spoke about what constitutes serious news, the best modalities for delivering serious news particularly in the wake of COVID, who might be the best person to deliver it, and the importance of the care team as a whole. We left off on the question, how do we prepare for delivering serious news? Let's continue the conversation. [MUSIC PLAYING]   TYLER JOHNSON: Katie was talking about how we need to be realistic about the way that a conversation is going to impact us in addition to the way that it's going to impact the patient. And one thing that I have realized is that a headline, for those who maybe haven't had evals of training, is just a concise summary statement of sort of the big picture of what's going on, just like buying a newspaper article. And what I have recognized is that oftentimes, I have this almost visceral reaction against giving a headline. And if I drill down just a little bit, what I find is I don't want to give the headline because then I'm really going to have to say things the way that they are, right? If I give a five minute disquisition on creatinine and edema and chemotherapy, immunotherapy, therapeutic options and whatever, right? Then, I can just like talk a cloud around things and never actually say what it is that I'm trying to say, which then gives me the advantage of feeling like I said it, but actually sort of knowing that I never actually said it, right? And so I think the thing that the headline does is it forces me to say the thing. And then once the thing is out in the open, then we can talk about, if necessary and appropriate, some of the other nuances and whatever. But all of that is to say that often, the greatest barrier to doing that is an unwillingness to be real with myself about the information that I'm really trying to convey. KATIE STOWERS: I think this is another really great opportunity where when partners go in together, it's easier to get into the moment if you get the opportunity. Someone with a little bit of accountability, but also somebody to help you. Maybe you're able to get out the facts and they're able to tie-in the meaning. Or you end up going bigger than your headline and they're able to say, I think what you were trying to say was dah-dah-dah-dah-dah, and help really get back to that core. STEVE BURNS: It does say that we all, before we share serious news, making sure whoever you're going in with, you're on the same page. And having a pre-meeting is so important. And what I often do with my pre-meetings is I come up with the headline as the group, right? So we're all clear about what is that headline so that when we go in, we can, in some ways, also hold each other accountable for that headline. KATIE STOWERS: I think also, a little bit of who's going to say it too. Like, is that something that you feel comfortable saying, or would it be easier for somebody else to say? Are there parts of it, and then parts of it that I can do, I think, can be really helpful. TYLER JOHNSON: Yeah. It's funny, because sometimes, even though I'm pretty tuned into these things and I try really hard to do them well, I still find that there are times as a medical oncologist when the palliative care doctor who is unfailingly ever so nice and gracious about it, ends up being like the real human translator for my medical leads. So I, like, say some word cloud. And then the palliative care doctor, like Katie just said, is like, if I can say that what Dr. Johnson was trying to say right there is something in normal human English speak. And then, as soon as they do that, I'm like, oh. But that can actually be really helpful. And again, I think it's obviously not meant to slight me. It's not meant as an affront, right? It's just sometimes, it's just kind of hard to quite get there, right, and to quite say the thing. And sometimes, having someone to help. Like, you get 80% of the way there, and then having somebody else get the other 20% is really, really meaningful. And it also, in a strange way, kind of allows us to share the emotional burden a little bit, right? So that it doesn't feel like, oh my gosh, this is just me saying this thing. There's something about having other members of the team there to kind of hold your arms up as you're doing that that's really meaningful. KATIE STOWERS: I worry that part of this conversation is saying like, oh. Some people are really good at this. Some people aren't. I don't think that this is a palliative care physician's good the whole time. I think this is a normal human experience. This just happened to me. This week in clinic where my patient was like, you just told me like a five minute story of things I already know. And I still don't know any more information. And I was like, oh, that wasn't really clear at all, was it? So I mean, I think it's when our nerves pop up. When we are uncertain or unclear about what it is that we want to say or just really nervous about doing it, like, I think this is our normal human default to go back to beating around the bush. But it definitely, as Steve mentioned, is a skill that we can learn and continue to practice. And it's also really helpful to have somebody there who can hold your feet to the fire and help you in the moment. STEVE BURNS: Katie, I'm so glad you mentioned that. I just think about even for us as palliative care physicians, who do serious illness conversations all the time, catching ourselves doing some things because we are being affected by the conversation and our well-being. I remember a couple of weeks ago, how hard it was for me to say dying and death. And I know. I've been teaching my learners say the D word. It's OK. It's direct. It's straightforward. And then all of a sudden, I was in the middle of the conversation and I noticed I was struggling saying death. And so again, just to say we are human, that these conversations affect us. And having team support is so helpful in the moment. Because the chaplain who I was with said, what we're saying is we're worried that she's dying. And I was like, oh thank god. She said it. TYLER JOHNSON: And the other thing too, right, is that I think it's helpful in a sense to recognize that the difficulty with giving a headline or with saying death or dying or whatever is an impulse borne of human compassion. I mean, it's not because we're bad people. It's because we have good hearts and because short of maybe clergy members, there's really nobody else in the way that human ecosystems are set up that does this, right? It's just a hard thing to do. And recognizing that it's hard and recognizing that we ourselves are having a hard time with it, is not some failing of doctoring. I would say that actually, this is one of those weird instances where having that consistent struggle, that should be a tension that should define part of how we doctor. Because if the tension goes away, that's actually more worrisome than if the tension continues to be there, though we have to find productive ways to engage with it. STEVE BURNS: Yeah. We did a study in 2016, the Vermont Hospice Study, and similar to actually, what Cambia Health Foundation found, why people don't engage in serious illness conversations. And one of the biggest reasons was taking away hope or hurting people's feelings and in causing emotional distress. We also know with the literature that most patients, up to like 90%, 95%, want to know the truth because it helps them better make decisions. And I think we can deliver prognosis in a compassionate way. And I think practicing that in the kind and caring way that's person-centered, asking them, what do you know? Is it all right if we talk about this right now? Delivering in a headline and responding to emotion can help make that a more compassionate conversation. Although it still doesn't take away the human feeling that I'm worried I'm going to hurt someone in this conversation. TYLER JOHNSON: Almost always in my experience, patients who have metastatic disease, or for some other reason, disease that is known from the get-go to be incurable, in one of our first discussions, they will ask some version of the question of how long do I have, or what are things going to look like going down the road? There's good evidence to demonstrate, and it has also been my personal experience, that we're really bad at answering that question at the time of diagnosis, right? Because we don't know anything about the biology of the tumor, the response of chemotherapy, what the molecular markers are. There's a whole host of things that just make it so we almost always cannot answer the question accurately even if we try. And so what I will usually do is I will tell patients, I'll say, when they ask some version of that question, I'll say, look. I need you to know that, first of all, I can't answer that question right now. I'm not obfuscating. It's just, I would be lying if I gave you an answer because we just don't know. But I want to let you know that what is true is that I can usually tell when things are starting to go in the wrong direction. And unless you ask me specifically to do otherwise, I promise you, the patient, that as soon as I recognize that things are heading in a direction that I'm concerned about, I will tell you that in so many words so that you understand what I'm talking about. And then we will have a discussion about where to go from there. And then, when we get to that point, whether it's six weeks later or six months later, or sometimes six years later, I will say-- because I do this with all my patients-- I'll say, do you remember when I made you that promise way back when or a few months ago, whatever it is? And then I'll say, I hope that I'm wrong here. But I'm concerned that we may now be in that place. And I want to tell you why, and then I want to talk about where to go from there. Because that then situates this difficult discussion in the context of this relationship of trust that we've been building over however long I've known the patient. And I have found that that provides a trusting context within which to have the more difficult conversation that has been really helpful. STEVE BURNS: Noticing the time, I'm curious, how does the task of delivering bad news affect your own well-being? TYLER JOHNSON: Just to remind people, we said this before, but I just think it's important to recognize that this being a heavy thing is normal. And recognizing that is normal and that it really is-- I mean, there's some degree to which you can do this well and that will lighten the burden to some degree. But you have to make sure that you're filling your own reservoir, right? You can't pour empathy out of an empty reservoir. And so I think you have to make sure that you're filling that in whatever the ways are that you do. KATIE STOWERS: I just think I was thinking about that too, Steve. One other thing that I wanted to build off of, this fear and this worry that we bring to these conversations, that I'm going to send them into a tailspin of depression. Or I'm going to take away all of their hope. I think there is the other part of this that I get to see as a palliative care physician, which is the high degrees of distress that often come from not knowing this information, that's really helpful in preparing and planning for the future and almost this sense of relief. Even when it's unfavorable, even when it's not what they wanted to hear, there's a relief in knowing and being able to do something with it. So that limbo and uncertainty. the idea that something terrible is out there or they can't prepare for it can be really distressing. And so to some degree, we're helping to heal by being able to move into some planning. STEVE BURNS: Yeah, I totally agree that it's such an important thing to minimize the stress of uncertainty. And the other piece that I think about is these are really sacred moments where we can really connect with our patients, share the news, find out how they're doing with it, and then find out what really matters in their lives. I think that really helps be my north star when it comes to continuing the care that I'll provide for them in their families. TYLER JOHNSON: Yeah. You know, there's a really harrowing, in some ways, but beautiful moment. And many of you will probably have read the book Just Mercy, which is written by this lawyer who's fighting for justice, particularly racial justice, for people who have been unfairly treated by the justice system in the deep South. And there's this moment towards the end of the book where a person who he had been fighting for who was on death row has just finally been executed. And he goes home and sort of just collapses crying. And then he writes really beautifully about how this moment of sort of shared vulnerability, where he kind of recognized that the reason that this was so hard was because even though he was vulnerable and broken in different ways than the person who had just been executed, it was still sort of a shared sense of vulnerability. It was what made his work hard, but also what made his work beautiful. And I think that in a similar fashion, when we have these really difficult discussions, I think that while there is a real moral weight and difficulty to it, there is also just as you said, they also end up being some of the most meaningful, memorable, and beautiful moments. STEVE BURNS: As a clinician, what have you learned over the years regarding communication with patients that may help others navigate scenarios where they can deliver serious news? I was just on service with a trainee. The team was delivering serious news. It was serious news around lung cancer. And the team's like, this patient's just not getting it. And we tried to explain it over and over again. And they're not getting it. And then my trainee went in and attempted and said, yes. Here's your diagnosis. We're concerned it's incurable. And you likely will die in the next year or so. And the patient said, no. I'll be fine. So we hypothesized before going in the room with me, like, what it would be. And what it came out is maybe it's not they're not understanding it. Maybe it's emotion. So we went back in. And sure enough, my trainee did wonderful and responded to emotion and said. It must be really hard hearing this news. And the patient immediately got sad and said, I'm really scared. And we unpacked that a little bit. And when we left the room, he said to me, yeah. That was emotion. He totally gets it. He's just upset. And so I just want to reiterate the idea, sometimes, it's not that they're not understanding it. It's that it's a lot to process. And there's a lot of feelings behind it. KATIE STOWERS: Building on that, one of the things that I see happen a lot around emotion is the health system is not set for people to process and to come to terms with these hugely life things and life-altering things. There's not time for people to process what this means for their life to term and process that emotion. And we're constantly pushing. And sometimes it almost could feel like badgering, really trying to get a decision to come where, with some degree of autonomy and some degree of time, allowing them to really process. People, a lot of times, get to where they need to go. But it's a process of really being able to deal with. STEVE BURNS: Yeah. TYLER JOHNSON: Yeah, the only thing that I will add is that these conversations, when they need to happen, work best when I have been mindful of laying the groundwork for the conversation over the entire arc of the illness. Rather than thinking of, oh, this is the thing that I do right when someone is getting close to dying. Because if you've never laid the groundwork and then you try to have the discussion, then when the person is really, really sick and in the hospital or whatever, of course, there's still a better and a worse way to do that. But even the best conversation if it's that isolated incident, in my experience, is nowhere near as good as if we have been transparent and building trust and building a sort of a shared vocabulary with the patient over the course of the illness. So that then, when they get to having to have quote, "the discussion" unquote, it becomes just one part of this longer chain rather than an isolated happening. And that really gets to what I was saying earlier about the promise that I make my patients when they first ask that sort of big picture question. That even though I'm not in a good place to talk about it right then, that I promise them that when it comes time, I will talk with them about that with candor. That makes an enormous amount of difference. I know I had a trainee who was with me one time who was a continuity fellow with me and had heard me make that promise to a number of patients and the first time he was with that same patient when it came time to have that discussion. And I said, well, you remember that promise that I made the first time I met you? And he could, for the first time, see all of the dots connect over the arc of the illness. It was like, whoa. Like, there's just really this power that comes. But you have to have been building it piece by piece over time. STEVE BURNS: I think both of you are highlighting for me two reminders that I want to keep in mind every day when I'm delivering serious news. One is sort of having an agenda but being flexible with my agenda. And I remember during my training, one of my mentors said, keep your agenda out the door. Don't force your agenda on the patient, as Katie mentioned. And yet, have a plan and still go in with that plan. The other piece that Tyler, you're reminding me of, is the importance of the arc of the conversation and how continuity. Because we build off of conversations from visit to visit. And yet, sometimes, someone else is taking over for us or they end up in a hospital or they end up in a nursing home. And it reminds me how important documentation is to convey what happened in that encounter. What was said, what was the headline that was shared, how did the patient respond, and then what was the plan. And far too often, we usually just write the results of the conversation. TYLER JOHNSON: Yeah. One last thing that I want to put a specific plug in that I have found to be enormously important, I think all of us would agree that amidst all the conversations that we might have as part of taking care of a patient, this is the one where shared decision-making matters the most. And yet, if you ask most people, even experienced doctors, how do you engage in shared decision-making around this kind of question? That's really tricky, right? Because I think what often ends up happening is that we either default to being very prescriptive where we go in and say, well, you should do this or shouldn't do this. Or we default to being waiters with the menu. Like, well. OK, so would you like some intubation on the side of CPR? And so, I think that both of those models are equally problematic and that the tool, the specific tool that has helped me really learn about how to do shared decision-making and even provides the specific words, is what's called the Serious Illness Conversation Guide from the Ariadne group at Harvard, which is the group founded by Atul Gawande and his colleagues. And I think that that gives a very brief script which, I mean, you can literally almost just read. You can get a little card that you can carry in your pocket or whatever. And it gives-- and the entire conversation in most cases, takes maybe 10 or 12 minutes. But it gives you the point-by-point things to say and really allows you to meaningfully engage in shared decision-making so that you spend the first half of the conversation listening to the patient's priorities and values, and then the last maybe third of the conversation, using that to make meaningful recommendations. And so again, it's called the Serious Illness Conversation Guide. And I would really recommend to listeners that they look it up. STEVE BURNS: That's a really great segue to what training and resources are there for clinicians and oncology trainees to improve their communication skills. The three resources that I can think about are Vital Talk, the Serious Illness Conversation Program out of Harvard and Ariadne Labs, and then they have a rich program which is from the American Academy of Communication of Health Care. All three are different ways of approaching communication skills training. I always think about the Serious Illness Conversation Programs about raising the floor to make sure that we hit the basics. And then Vital Talk is if you want to flex your muscles or flex your skills when it comes to how do I respond to really intense emotion, or if someone's avoiding the conversation, what do I do? They train with raising the ceiling or their goals to raise the ceiling. And Vital Talk actually came out of oncology conversations first with OncoTalk almost 20 years ago. And really thinking about not didactic-based, but practice and skills-based training. And I certainly have found it rewarding and life-changing for me, where I could actually label the things that I do every day, give myself some feedback, and then teach my trainees. TYLER JOHNSON: And I will just add, as a medical oncologist who has both taken the Vital Talk course and now is trained and teaching Vital Talk courses, that this is not just for palliative care doctors. And I think that it is particularly-- I mean, you may not have the interest or passion to want to become a Vital Talk trainer, which is understandable if you're a medical oncologist, either a busy practice or a heavy research portfolio. But it's just to say that they offer 1 and 2 and various iterations of courses, depending on how intensely you want to study these things. But it's just to say that the skills that they teach are concrete. This is not some sort of head in the clouds theoretical exercise. I mean, they're taught very concrete skills that you can wake up the next morning and employ you in your practice. And that I think to a point that is often counterintuitive to us, I think that we are almost afraid, as oncologists, to know about this because we think, oh my gosh. I didn't have time to engage in these long discussions. There's no way. But my experience has actually been what this does at the end, is it actually makes you more efficient. I know that seems counterintuitive, but we spend so much time sort of beating around the bush around this stuff that we actually end up making ourselves take longer. And having really concrete skills for how to have these discussions can actually make your practice more efficient for things that otherwise can really eat up a lot of time. KATIE STOWERS: I do a lot of teaching in Vital Talk incentives. It sounds like both of you do as well. But the piece of feedback that I hear from trainees that come take courses-- and I do a lot with oncologists and oncology fellows as well-- is oh, these are the things that I've seen in conversations at work that I never had a name for. Like, you're putting a name on something that I've seen. And maybe I've done a couple of times, but I didn't know that I was doing it this way. And especially for my colleagues who are practicing providers who teach others, they really love having a name and a framework for being able to teach these skills to others. It's not some magic fairy dust that you either have or you don't. It's actually, here's a skill that I can pass on to you and you can practice. And I can watch for, and we can have some feedback about. And I have seen that being a really enjoyable part of doing this framework. We have that, right, for almost every other part of medicine. But because communication is something that's so innate and personal, that hasn't always been the case around communication. And so I really love that about Vital Talk, that they've taken these pieces and put names on them. Because this is how you give communication clearly, information clearly, is the headline. This is how you show someone that you care about them. These are empathic statements. And that's something that we can use as a third language when we're going into team meetings together or when we're teaching a trainee. STEVE BURNS: It's one of the most important skills that we do every day, and probably the most important procedure that we do on a regular basis in all of our fields. TYLER JOHNSON: And I think you can tell from the way that the three of us have discussed delivering a headline during this podcast, that this is not like a thing that we learned seven years ago and then just sort of left in a drawer somewhere, right? Like, this is something that we're actively thinking about as we actually take care of patients every day, which is to say that it really is very applicable. STEVE BURNS: I feel like that's the time for today. This has been a really great conversation. Thanks so much for both of your insights and participation in this episode of the ASCO Educational Podcast. KATIE STOWERS: Thanks for inviting us. It's been great to be here. TYLER JOHNSON: Thanks so much. It's been a pleasure. [MUSIC PLAYING]   SPEAKER 1: Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive education center at Education.ASCO.org. SPEAKER 2: The purpose of this podcast is to educate and to inform. This is not a substitute for professional 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. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

In part one of a two-part conversation, Oncology, Etc. hosts Patrick Loehrer (Indiana University) and David Johnson (University of Texas) have a blast speaking with two physician astronauts. Hear the incredible stories of Drs. Robert L. Satcher (MD Anderson), Ellen Baker (MD Anderson), and their lives on and off this planet. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT Patrick Loehrer:  Hi, I'm Patrick Loehrer. I'm Director of Global Oncology and Health Equities at Indiana University. Dave Johnson: My name's Dave Johnson. I'm at UT Southwestern in Dallas. Patrick, we're excited to be back for another segment of ASCO's Educational Podcast, Oncology, Etc. We have two very special guests today, Drs. Ellen Baker and Robert Satcher, oncologist and former astronauts. So I predict this will be an out of this world segment. Patrick Loehrer: It's starting out pretty slow right now, with that one. Thank you though.  Dave Johnson:  Well, listen, this should be a great segment. But before we get started, do you have a favorite astronaut book?  Patrick Loehrer:  Well, the one I read this summer was called American Moonshot by Douglas Brinkley, and it basically took the story of John F. Kennedy and how the space race happened from 1960 and actually earlier than that, into getting onto the moon. It was really, I thought very extraordinary.  Dave Johnson:  So, I haven't read that yet. My favorite would be Rocket Boys by Homer Hickam. I thought that was a fantastic book about his life growing up in West Virginia and ultimately, becoming a NASA engineer and rocket scientist. So that was really great. Patrick Loehrer:  I read that several years ago after you recommended it. They made a movie out of that.  Dave Johnson:  Yeah, I think October Sky was the name of the movie. Yeah. >Patrick Loehrer: Yeah, it's a terrific book. Dave Johnson: Well, why don't we introduce our guests? You want to start with Dr. Baker?  Patrick Loehrer: Oh, sure. It's my pleasure to introduce Dr. Ellen Baker. I have known Ellen over the years through interactions in global oncology. She was born in Fayetteville, North Carolina, graduated from Bayside High School in New York, got a bachelor of arts degree in geology from the State University at Buffalo. A doctorate in medicine for Cornell, masters in public health at UT Public Health, and then trained in internal medicine at UT San Antonio. And during her residency, she decided to join in the NASA program as a medical officer. And it was actually, she did a residency around the same time I did, and I remember the space call for astronauts at that time. She was selected as an astronaut in may of 1984, had a variety of jobs. She's logged more than 680 hours in space and has been a mission specialist. She retired from NASA in 2011 and is Director of the MD Anderson project, Echo Program in which he does projects in rural Texas, as well as Zambia, Mozambique, in Central and South America. It's such a great pleasure to have you here today, Ellen.  Dr. Ellen Baker:  Thank you, Patrick.  Dave Johnson:  Our other guest is Dr. Robert Satcher, currently an Associate Professor in the Department of Orthopedic Oncology Division of Surgery at MD Anderson, as well. Dr. Satcher grew up in Hampton, Virginia. He's the son of a university professor and English teacher, so I'm sure they made him do all of his homework. He received a bachelor degree, as well as a PhD in chemical engineering from the Massachusetts Institute of Technology and received his MD degree from Harvard. By the way Patrick, Dr. Satcher enrolled at MIT at age 16 and graduated at the top of his class. Later, we'll find out what you were doing at age 16? Patrick Loehrer: I do have to interject that I was a mechanical engineer at Purdue, and it's like being in high school compared to chemical engineers. Dave Johnson: Yeah, there's a hierarchy in the engineering world for sure. Dr. Satcher's medical degree was followed by internship and residency in orthopedic surgery at the University of California, San Francisco. In addition, he did a post doc research fellowship again at MIT and University of California, Berkeley. And completed a fellowship in muscular skeletal oncology at the University of Florida, before joining the faculty at Northwestern in Chicago. You guys have a lot of connections it seems? Not satisfied with that massive amount of education and training, Dr. Satcher went on to NASA to train as an astronaut, culminating in a flight aboard the space shuttle Atlantis in November of 2009. Apparently, he got a little bored cooped up in the shuttle because he took a couple of space walks, which I'd like to know more about. In fact, I read on NASA's website that he did some lubricating on one of his walks. I'm not sure what that's about, but I assume there's not a lot of gas stations in space. I also read that he repaired one of the robotic arms, which seems perfect appropriate for an orthopedic surgeon. You'll have to tell us more. Anyway, while these achievements would be enough for most people, it only begins to scratch the surface of the many accomplishments of Dr. Satcher's career to date.  I really can't cover it all, but our audience should know that Dr. Satcher's has been involved in a number of community activities, as well, ranging from his involvement in Big Brother for Youths at Risk, counseling program, to serving as a lay minister in his church. He's also undertaken a number of medical mission trips to underserved areas in countries, such as Nicaragua, Venezuela, Nigeria, and Gabon, where he once served as a Schweitzer fellow at the Albert Schweitzer Hospital in Lambaréné. Dr. Satcher, welcome to Oncology, Etc., we very much appreciate your joining us. Dr. Robert Satcher: Thanks Dave. Glad to be here. Dave Johnson: Perhaps I'll start by asking the two of you, if you could give us just a little bit about your background, other than what we've stated and what got you interested in medicine and how you got interested in space? Dr. Baker, maybe we'll start with you? Dr. Ellen Baker: I've always been interested in space. I was a child of the '60s, and I think one of the very memorable parts of the '60s was the US Space Program. It was a fairly tumultuous decade in the US, I think otherwise, and the space program was really literally a shining star. However, there were no girls in the space program at that time. Right? There were no girl astronauts and so I thought about it, but it didn't seem like it was even possible. I come from a family of medical people. My mother was a nurse, my father was a doctor, my brother is a doctor, and so that had a lot of influence, I think, in my choosing to go into medicine. And in fact, my brother is an oncologist and though I am actually not an oncologist, I've been hanging around with him long enough that some people think I'm an oncologist. So I think that's what got me pointed in that direction. Dave Johnson: Your brother is Larry Schulman, by the way, right? Humanitarian of the Year Award from ASCO, a couple years ago. Dr. Ellen Baker: It is, yes, and he is a great humanitarian. I was actually at my last year of medical school when I saw a little article in the New York Times that NASA was selecting new astronauts and women and minorities were urged to apply. And I kind of filed that away and went off to do my medicine residency and at the end of my residency, I applied to work for NASA as a physician. And that's how I got to Houston and to Johnson Space Center. Dave Johnson: Dr. Satcher, what about yourself? Dr. Robert Satcher: I got interested in space and being an astronaut when I was a kid too, and I was watching astronauts land on the moon. And I was sitting there listening what Ellen was saying and yeah, it was a time where all the astronauts were of course, white males and I didn't see myself there walking on the moon, but I knew it was something that I would really like to do, but didn't really see a way either, at the time. So it really was with the shuttle era that women, people from underrepresented groups finally had the opportunity to become astronauts. And right around the same time too, was when I was starting as an undergraduate at MIT and had the good fortune of meeting Ron McNair, who got his PhD from MIT. And that was the first time I ever saw someone who looked like me, who was an astronaut and that planted the seed that maybe I could do that one day. I also come from, as you mentioned, a family that values education and we've got a number of physicians in our family. Most famously my uncle, Dr. David Satcher, who was Surgeon General of the Clinton Administration. And I always remember, this is a funny story I like to tell if he's listening. When I was going around getting advice on whether or not I should stick with medicine or think about applying to become an astronaut, he advised me just to stick with medicine. So didn't take his advice, this is the one time I didn't, but I did take his advice, in terms of going to medical school. And I wound up applying to become an astronaut, right actually, before the Columbia accident and so they actually paused taking astronauts for a number of years. And in those years, actually that's when I went to Northwestern and was on faculty there. So they opened it up again and that's when I submitted my application and I was in Chicago and was selected from there. Dave Johnson: There's a number of questions that spill off from that. You guys may know David Wolf, who's an astronaut, who's from Indiana University. I had him in my clinic when he was a medical student and as I always do, I basically say, "What do you want to do when you grow up?" And he said, "I want to be an astronaut." And I just smiled and I don't think I ever went back in the room with him, I just figured, "This guy is a flake, what's going on with him?" And I think he's logged more space miles than just about anybody, he's an incredible human being. And again, if he's listening, you're terrific. David. Patrick Loehrer: I just have to ask this as a boyhood thing, because I did contemplate being an astronaut because I was an engineer and MD just like you were Ellen and so were you Bobby. But it hit me, one is, you have not to be afraid of heights, I think. And then, you have to be willing to go around in a circle a thousand times a minute and not throw up. But in the training there, did any of that stuff bother you or was this no big deal? Dr. Ellen Baker: That sounds a little like Hollywood and not so much like the real thing, actually. In the early days of the space program, they did put astronauts in rotating chairs. I'm not exactly sure why? But we don't do that anymore. I would say that the training is rigorous, but it's not unreasonable. I don't know what you think, Bobby? It's fairly predictable. And I will put a little shout out for Purdue, which maybe has one of the highest number of astronauts of any university outside the military academies. I don't know if that's true now, but 10 or 15 years ago, we just had a large number of engineers from Purdue who were in the astronaut office. Dr. Robert Satcher: I agree, the training is not quite how it's portrayed sometimes in the media. The question I get asked from my doctor friends a lot, "I guess you can't be claustrophobic going into space because you're in the space capsule." And that really does deter a significant number of people, probably more than myself or Ellen appreciate because I'm always surprised when I get that question. Dave Johnson: But I'm 100% sure I couldn't be an astronaut if claustrophobia is an issue because I can't stand to be in an elevator. Dr. Ellen Baker: Let me step back a little, I don't want anybody to get discouraged. But you'd be surprised at how many pilots have a fear of heights if they're not encased in an airplane. So fear of heights is not necessarily something that you might worry about if you're an astronaut. And I disagree with you Bobby, I don't think space vehicles are claustrophobic. It's not like being in a submarine, which I would find very claustrophobic. Particularly in the shuttle because we actually had great windows and great views and we didn't feel confined. I don't know what you think Bobby, but I didn't think it was like being in a cave or closet or a submarine. Dr. Robert Satcher: Yeah, I definitely agree with that, the views are spectacular. Patrick Loehrer: So William Shatner just went up and had a brief stint in space and is now considered an astronaut, but he came back with such a sense of awe. Can you describe a little bit what it's like, the view from up there and how does it leave you, particularly your first time up in space? Dr. Robert Satcher: The words don't completely capture it. The colors are so vivid, the view is so breathtaking. It's really impressive seeing the Earth, not only at daytime, but at nighttime and it goes beyond. It's one of a few things I always tell people, that really exceeded my expectation, in terms of what my preconceived notion of what it would be. And ever since going, that's what's so addictive about going into space, it makes you want to go back just to see that again and experience it again. The closest that I've come to seeing anything like that is, they have these new virtual reality experiences, where they actually got footage that they shot in high-def on the space station, outside the space station. It comes close, in terms of the look but it still doesn't fully capture it because the colors and everything, aren't as clear and crisp as it is when you're there. Because you're in the vacuum of space and there's nothing interfering with it and it's just spectacular. Dr. Ellen Baker: Yeah. I'll jump in here too and I absolutely agree with Bobby. And the other thing is, you orbit the Earth every 90 minutes, so you cover a lot of ground and you see a lot of the planet and in that one orbit, you get a sunrise and a sunset. So you orbit the Earth 16 times a day and get 16 sunrises and sunsets, so every 45 minutes the sun is either coming up or going down. It's really hard to know what time of day it is, in terms of your work day in orbit, but it's just magnificent. And it did give me a sense that we're all from the same planet and of course, it makes me wonder why we can't all get along better? Patrick Loehrer: I think people our age remember a few things, we remember the day Kennedy was shot. We remember the landing on the moon with Neil Armstrong. We also sadly, also remember the Challenger disaster and where we all were at that point in time. Ellen, you were an astronaut at that time. Dr. Ellen Baker: I was. Patrick Loehrer:> Can you reflect a little bit about that, if you can? I'm not sure I could do it without getting emotional, if I was there. Dr. Ellen Baker: Yeah, I was actually at work of course, and watching the launch and it was just devastating. Obviously, I knew everybody on board, I knew their families very well. And I have to say, we knew flying in space was risky, but we were still pretty unprepared for Challenger and for Columbia. It is something that I still think about. As weird as it might sound, I actually rescued the plant from Dick Scobee's office. He was the Commander of Challenger and I still have it growing. So it's a reminder that he was a good friend and a good colleague, it was a terrible blow, as was the Columbia accident. In that same tradition, I have African violets by my sink that were in Laurel Clark's office and Laurel was a physician who was aboard the Columbia, as well as Dave Brown, who was also a physician on the Columbia. Dave Johnson: That's an amazing tribute to both of your colleagues. It's very touching to hear that. I wonder if the two of you could share with us, what you actually did on your missions scientifically? How did you use your medical knowledge, if at all? And Robert, what about your oncologic knowledge, was that useful at all? Dr. Robert Satcher: Fortunately, no use for the oncology training in space. I got to use the orthopedic training. One of the most common problems is back pain the first few days when you're in space. We attribute it to, you're going into weightlessness and all of a sudden, there's these fluid shifts, you get more fluid in your inner discs, everybody gets taller. Dave Johnson: Well, let's send Patrick to space. Patrick Loehrer: We need to get up there soon, Dave. Dr. Robert Satcher: Yeah. Actually, during our visit, we measured everybody's height just so that we know what that change was and we did do a experiment actually, that my background came very useful for. We were looking at the effects of bisphosphonate on bone loss. So bisphosphonates, well, everybody knows, this is ASCO, a class of drugs, anti-absorptives, used in patients with bone metastasis. It was actually being tested in rats, thinking about countermeasures for keeping people from losing bone in long duration, space trips. Unfortunately, bisphosphonates come with a lot of effects. But it did seem to work, in terms of the bone mass, which is induced by weightlessness in rats. And then finally, I was the crew medical officer for my group because I was the only MD up there in our crew. Ellen probably was the same in hers. So, what that involves is, NASA was one of the first places to pioneer use of telemedicine. So, you're basically, communicating with the flight surgeons on the ground every day, talking about what sort of medical issues there are with the crew and getting their recommendations for dealing with whatever it is. So yeah, being a doctor actually came very much handy. Dave Johnson: I was going to ask both of you. During your flights, did you encounter any medical emergencies without violating HIPAA? I mean, did you have to do an appendectomy? Dr. Ellen Baker: No appendectomies and fortunately, no emergencies, astronauts are pretty well scrutinized and examined before flights. And I think the best insurance against a medical problem in space is to send crews that are really fit and really healthy. And of course, there's always the risk of things like trauma, but the risk is actually fairly low. So no emergencies on my flight. Patrick Loehrer: There's no RVUs up there are there, that you have to worry about billing or no? Dr. Robert Satcher: No, we didn't have to deal with third-party payers. Patrick Loehrer: This is looking more and more like a job I want to pursue here, I'm going to be taller and there's no billing. This is great. Dave Johnson: I want to hear from Ellen, what sort of experiments she was involved in and how her medical background helped her assist with that? Dr. Ellen Baker: Yeah. People think, "Gee, if you're a doctor and you're an astronaut, they selected you to be a doctor in space." But in fact, astronauts are selected sort of generically. So once you come into the office, you're trained as an astronaut and Bobby and I were both mission specialists, as opposed to astronaut pilots. And so we received training on all sorts of different things. Bobby did a space walk. I trained for space walks, but never did one. We trained on the remote arm. We trained how to fix things when they were broken. I was actually a flight engineer on one of my flights. But that aside, I was also the crew medical officer and on every flight astronauts participate in medical experiments, because we are trying to gather lots of information from very few people on the physiologic effects of space flight, particularly looking towards longer flights, perhaps back to the moon or to Mars. So I did participate as a subject, I was an operator in a few medical experiments, but the bulk of my responsibilities actually were not medical. And I think Bobby, maybe you would agree with that? We did have some flights that were designated as what I would call, space life sciences flights, but there was only a handful of them and I was not a crew member on any of those flights. Patrick Loehrer: Boy, I could spend another three hours on this and would love to hear more stories. Dave Johnson: This concludes part one of our interview with former NASA astronauts, Drs. Ellen Baker and Robert Satcher. Please be sure to tune in to part two of the interview, where we will learn more about the incredible work they're doing in their post NASA careers. Thank you for tuning in to Oncology, Etc., an ASCO Educational Podcast. If you have an idea for a topic or guest you would like us to interview, please email your suggestion to education@asco.org. Thank you for making Oncology, Etc. a part of your day. Announcer: Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click subscribe, let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. Announcer 2: The purpose of the as podcast is to educate and to inform. This is not a substitute for professional 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. Guests statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy, should not be construed as an ASCO endorsement.

In part one of this two-part ASCO Education Podcast episode, Drs. Stephen Berns (University of Vermont), Tyler Johnson (Stanford Medicine) and Katie Stowers (Oregon Health & Science University) chat candidly about what it takes to deliver serious news to people with cancer effectively and compassionately. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: education.asco.org | Contact Us Air Date: 2/16/22   TRANSCRIPT Steve Burns (Dr. Burns):  Hello. My name is Steve Burns. And I am a Hospice and Palliative Care Specialist and Associate Professor of Medicine at the Larner College of Medicine in Vermont. I’m pleased to moderate this episode of the ASCO Education Podcast focused on clinician patient communication in the context of delivering serious news to patients and family. I am joined Katie Stowers, a Hospice and Palliative Care Physician and Assistant Professor of Medicine at Oregon Health & Science University and Tyler Johnson, a Medical Oncologist and Clinical Assistant Professor of Medicine at Stanford University. Well, this is a serious discussion on delivering difficult news to patients and families. It is an extremely important one that I’m glad to be having. Let’s first start with our question, what is bad news? I’m delighted to answer the question first mostly because I have an issue with calling it bad news. It really comes down to some of the training that I had as a palliative care physician when one of my attending said, don’t assume it’s bad. And I remember an example that I had for one of my first couple of patients, where the patient, when we were explaining that she had metastatic cancer and that she was likely going to die from this illness, she said, “Oh my gosh. I’m so relieved because I’ve been looking for an answer for months.” So what made me realize during that moment and also what my palliative care attending reminded me of is don’t assume. And this is consistent with a study that came out, I think, by Anthony Balkin like 2011 where they did a qualitative review of patients encounters with serious news and bad news. And patients actually gave feedback that said, “We don’t want the physicians to judge our news.”  Again, sort of reframing that, it’s better to call it serious news rather than bad news. Dr. Tyler Johnson (Dr. Johnson):   I’ll build off of that and just say that I think it’s also important that we recognize that sometimes when we call something bad news, what that’s actually reflecting is what our experience is going to be or what we anticipate that our experience is potentially going to be, which is totally fair. It’s absolutely valid to say having to share this news is going to be a difficult part of my day. And therefore, I think of this as sharing bad news. In fact, I think that recognition is important and can lead to important reflection and even to self-compassion. We should be candid about the fact that this is a hard part of our jobs. I mean, who likes to share life-changing, sometimes devasting news with patients?  Nobody wants to do that. That’s never going to be a fun part of your day. I think, though, that it is important to recognize that that’s a different question from how the news is going to land to the patient.  Sometimes those things will match up and sometimes they won’t. And it’s important for us to be circumspect and careful in the way that we think about both how the news is going to impact us and how the interaction is going to impact us and also how it’s going to impact the patient. Dr. Burns:  I’ll move to the second question, which is what is the ideal circumstance or modality, in person or video call or telehealth, to deliver serious news to patients? Dr. Katie Stowers (Dr. Stowers):  I was actually struck on reflecting on that question about the ideal modality. I think COVID has actually really changed the way that I think about that question. Pre-COVID, I would have said hands down, everybody sitting in the same room being able to reach out and touch someone or be able to see them. But COVID has actually changed that. The people who need to be there aren’t always able to be there because of hospital visiting restrictions. And being in the same room often means three layers of PPE between you and the people you’re trying to talk to when they can actually see your face. I found some really meaningful encounters of delivering serious news that’s been able to happen virtually in a way that I think I would have really surprised about pre-pandemic. I just had a patient in clinic with me a couple weeks ago who we were sitting there face-to-face, but visitor restrictions in our cancer center still wish she couldn’t have anyone with her in the clinic. And so we were sitting there together and she wanted information. She wanted to review information that her oncologist had given her about prognosis. And so we were going to start to talk about that, and immediately she became overwhelmed and well, let’s get my family on the phone. And I would really like somebody else to hear this information. And ultimately we realized after trying to get people on and not being able to contact them that actually the best way to do this was going to be a virtual visit where she was home with her sister, with her dog in her lap, her aunt in New Mexico and her uncle in Alaska were all able to come on. We were all able to share this information together. And it was this really lovely moment where she had all of the things that she needed, and it had nothing to do with being in clinic. In fact, clinic brought a whole different set of stressors. And so I think the way I’ve looked at this really is different and it’s what does this person actually need? Do they need me to be able to physically touch them or do they need their support system? Do they need to be able to see my face without a mask? What is it that this individual needs? And I think that’s more of how I go in and approach thinking about the ideal circumstance now. Dr. Johnson: Yeah. I think that there is a lot of truth to that and because we are so constrained and clinic often now.  The one thing that I will mention as a practicing oncologist that I have recognized is really important, though, if you’re going to try to leverage the advantages that can come with technology is that it’s really, really important to make sure that the patient is tuned in to the kind of conversation that you’re going to be having before you launch into a discussion where you’re going to be talking about serious news. Because what we have found is that often when people are coming to see us, it’s part of a multi-hour half day or even a full day. They come in and see us. Then they get their labs drawn. They go to the waiting room. Then they go to get their chemo. Then they have to sit for a minute and be monitored afterwards. And sometimes it can be six or seven or eight hours. The reason I mentioned that is to say that what we have found is that many of our patients, for instance, are now having video visits with us, where we can tell them. They’re like in the car driving in to get their labs done. And they love that because they’re able to save an hour or two of time instead of sitting in our waiting room, they’re doing the visit in the car. But as wonderful as that is for efficiency for somebody who’s riding the chemo train, that’s not the place that you want to be having this kind of serious discussion. And so I think that if you know that you’re going to be having a visit that is going to involve sharing serious news, it’s really important to say, “Hey, I just want to let you know that this is going to be a particularly important discussion. Can you make sure that you’re in a quiet place where you can really focus here and have whatever family members or friends or whatever, your support that you want there so that they’re keyed in a little bit?” Because if they’re in clinic, we talk about preparing the right space. It’s better to do this in a private room in the hospital than in an Emergency Department with 27 things going on you. So by the same token, I think we have to give them the opportunity to sort of prepare the environment to allow them to have the best experience. Dr. Burns:  I agree with both you Katie and Tyler. I think about most of my work’s done in the inpatient setting and just thinking about even in the inpatient setting, making sure that even though a patient has their own private room, sometimes they don’t and they have a neighbor that they’re sharing it with and thinking about how do we create that privacy for them? How do we incorporate their loved ones, whether that’s actually using now a iPad that rolls in where you can now have a Zoom conference with their loved ones across the country or across the globe. But the other piece is really thinking about not tacking it on to the end of your rounds, but really setting aside some time to do that. And that’s even physically having someone hold your pager, silencing your phone so that you can be present for that conversation, just like how Tyler described that in the outpatient setting. Dr. Johnson: Yep. Totally agree. Dr. Burns: Well, thinking about who should be involved in the conversations, do you discuss as a team, which member of the cancer care team will deliver bad news to the patient and family? Dr. Johnson: I can maybe address this one first and then you guys can add on. I think I come at this with a slightly different perspective because I’m actually a practicing medical oncologist. I’m not a palliative care doctor. I actually think that there are important points to be made on two ends of a spectrum here. What I mean by that is that one thing that I is important is to recognize that there is more kinds of healthcare providers can be involved in these discussions than we sometimes may think. So for instance, Manali Patel, who’s a health services researcher here at Stanford, has done a lot of really interesting work lately with lay health workers being able to help have the first parts of these discussions in terms of exploring the values and priorities and needs of the patients.  And basically what she’s shown is that while there was initially a lot of skepticism, how can a layperson be involved in those discussions. After some training, these people actually do wonderfully well. I think by the same token, there are many members of the healthcare team that can help with that part. Having said that, I do think that there is also then a part of it that most patients appreciate coming from one of their primary healthcare workers. I think that as oncologists, we’re here talking to the American Society of Clinical Oncology audience, I think it’s important that oncologists recognize that there are certain things that patients really want to hear directly from you. And I think that in particular, some of the harder things to say, like we really don’t have other meaningful treatment options left, that phrase I don’t think land in quite the same way if it comes anywhere but from the treating oncologist because there’s always going to be this thought in the back of the patient’s mind that maybe my oncologist has something else in line or I need to talk to them later or what have you. I think that while on the one hand, we should broaden the spectrum of people who can be involved in these discussions, I do think on the other hand that it’s important to recognize that there are some parts of this that really are most effective when coming from the treating oncologist. Dr. Burns:  Tyler, I think you hit on the importance of the relationship of the oncologist and the oncologist team with the patient and their loved ones. I often think of out this tide of care cartoon. I think it’s almost like a far side cartoon where it’s a physician who’s sharing news to a patient and says I have some really bad news. So I’m going to get someone else to say it for me. I often feel like, as a palliative care physician, I sometimes am thrown into the mix. Am I the one delivering this news? What I really enjoy is partnering with the oncologist and even joining together when we can or for me to check in with a patient after the news is delivered, just because of how important that relationship is between the patient and their oncologist. The only other thing that I would add is I love having a team with me during those meetings. And so if I can in the outpatient center or inpatient setting, having a nurse or a social worker or a chaplain join me because sometimes I misstep and I say more than I should or I don’t notice emotion. And I think having the other interprofessional lens there to watch and observe can interrupt me, give some feedback in the moment and/or take a step back so that we make sure that patients understand on what’s going on. Dr. Stowers: I think, Steve, the part that I love about delivering news with the team is all the things you said. And when I notice my own emotions or I feel stuck on what to say, there’s somebody there who can kick the ball and run with it for a bit so I’m able to catch back up. I wanted to add on to something else that you were saying, Tyler, about this relationship between patient and oncologist. And I see that a lot where patients will come to me and they’re not ready to talk about things until they’ve heard it from the oncologist first. I just have got this morning this guy who got discharged from the hospital and hospice had been brought up in his visit, but he sees his oncologist on Friday and there was no way he was going there with me and how he’s able to talk to his oncologist rightly so. I also see the flip side of it not too infrequently where the relationship that the patient has with their oncologist is they’re the gatekeepers to life prolonging treatments. And they see any discussion of worries or fears as a weakness that maybe will make it less likely for them to get those treatments. And so I also see that patient population where they see me as the place as a palliative care provider where they can talk about some of those things that they’re not ready to talk about with the oncologist. They need the oncologist to be positive treatment focused and they need another place that’s not the oncologist to talk about those things. Dr. Burns:  Yeah, Katie, I just actually had a case like this last week where a patient says that she is really tired of the chemotherapy she was getting. She has a head and neck cancer, but she was afraid to bring it up with her oncologist because, she says, “I need to be brave in front of her.” And I just thought how interesting that was. And so every time she’s in the room with the oncologist, everything’s fine, everything’s great. And then when she’s speaking to me, she’s like not everything’s fine and not everything’s great. And so I just think that the illustration of, yes, it would be great as a team, sometimes when we individually approach it, people do feel comfortable saying something differently outside of their oncology visit. Dr. Johnson: I think that one thing that this all gets to that I think is what all of us are saying, but it’s worth articulating is that, Steve alluded to that cartoon at the beginning of this part of the discussion. The sort of underlying message from that is this idea that we as medical oncologists involve palliative care doctors if we don’t know how to do something or we’re not interested in doing it. And of course there may be times when the patient is better off with a skilled palliative care doctor doing the conversation that maybe a less skilled oncologist doesn’t know how to do so well. But that’s certainly not the optimal outcome. The optimal outcome is that there is teamwork and a partnership between medical oncology and palliative care. I think that teamwork creates a synergy where, because you’re right, that the patient may have one face that they put on for the oncologist and a different face that they put on for their palliative care doctor. And I know there are times when I can sense as the oncologist that there is something just below the surface that they’re not quite ready to bring up to me. And sometimes in those cases, I will say at the end of the visit, “I think this would be a really good time to touch base with the palliative care team.” And what I’m really thinking is because there’s clearly something else you need to talk about that’s not going to come out right here. So I want it to come out when you get to meet with them. Then of course, especially in those kinds of cases, having a little bit of back channels communication after the visit with me so that I can prep the palliative care doctors and let them know that I feel that there is something else there to be addressed, I think is really important. Dr. Burns:  One question to think about is how do we prepare? How do you prepare for delivering serious news? I think I will say that the first thing I like to do is do my biopsy of the situation. I know that’s quite medical to use as analogy, but I like to know who are the players? What is the prognosis? And what I need to do is do a really thorough check-in with the specialist. So oncologist or if there’s a radiation oncologist involved to check in with them and to actually check in with the patient about information preferences and/or who would like to be in the room or who they would want to be in the room. I think all of that helps prepare it. I always use the analogy with my trainees, like a good, serious illness discussion or a good delivering of serious news is a lot of preparation, just like how we learn to put in central lines. A lot of it’s the prep and then the central line when you place it is pretty quick. And so I certainly think about delivering serious news in the same way. Dr. Stowers: I think the part of preparing for serious news that we probably don’t think about as much is the part about preparing ourselves for giving this serious news. And Tyler, you alluded to that earlier on in the conversation of what am I bringing to this conversation? I, through a series of tough experiences when I was a new palliative care physician in a busy outpatient practice, really found myself losing the empathy that I really prided myself on having in my clinical encounters. And I walk in and be like looking at the clock, like tapping my foot as this person’s crying in front of me and like, holy smokes, what’s going on here? And I realized that I was not prepared to give this kind of news. And so really started instituting before I knock on the door and go into the office or click the virtual visit now as it, I’m making sure how am I? Have I gone to the bathroom? Have I eaten? Am I hot? Am I cold? Like how does this patient make me feel. What are the emotions that I’m bringing up? What are the biases that I’m bringing to this about what outcomes do I really want from this conversation and doing this little mini-checklist of how am I and what am I bringing to this conversation has really helped me get a lot more centered before I walk into their room. And so I think that that should absolutely be on that checklist that we do as we’re preparing for these conversations. Dr. Johnson: I’ll say two things building off of those great points. One is that I think, to Katie’s point, I think it’s important that we put a plug in here for a holistic evaluation of your own wellness as a doctor in the big picture perspective. And obviously, I have my own bags under my own eyes after the last two years of the pandemic. You can choose if I’m the pot or the kettle, but I recognize that I struggle with this just as much as anybody.  But it’s just to say that if you’re not eating well and you’re not sleeping well and you’re not getting some exercise and you’re not taking time for yourself and you don’t have a sense of self compassion, it’s very difficult to fake empathy. It’s very difficult to pretend to be present. And if you try, it usually just doesn’t really work. I mean, you kind of either are present or you’re not. But the issue is that you can’t summon self-care in the moment that you need it. You can maybe try to do that for a couple of days. I think that largely is what burnout is. It’s trying to magically materialize self-care as if you can do that the moment before you walk into a room and that’s just not how the human psyche works. So that’s thing number one. The other point that I would make is that, and I feel like this is one of those things that I just have to learn a thousand times over the course of being a clinician, because no matter how many times I learn it, then I forget it and it blows up in my face and I think, oh, well, yeah, I forgot that lesson again is how important it is that the first thing I do when I get in with a patient and I’m preparing to have one of these discussions is to talk with them about what they already understand about what’s going on. Because you have some patients who you’re surprised to find that you know that they’re on end of line chemotherapy and they have overwhelming disease burden, etc., and then you ask them what’s going on. And they say, “Well, I’m just really excited for the next chemo because doc, you said that the next chemo was going to be the one that was going to make the difference.” when of course you probably think you didn’t say that. But the point is just to say, that’s very different than if you ask the patient and they say, “You know, Doc, I so much appreciate everything you’ve done. If I’m really honest, I kind of feel like I’m dying. I think that’s where I am.” Well, those are two totally different discussions. And if you come in assuming either of those things and it’s actually the other one, then you’re either going to waste a phenomenal amount of time or it’s just going to be a terrible encounter. And I’ve made mistakes on both ends of that spectrum, which just reemphasizes for me the importance of figuring out where the patient is before I start saying anything. Dr. Burns:  And Tyler, I also think about the efficiency of these conversations. Often we are so worried it’s going to take so much time. And when you start with, what have you been told or what do you understand or what’s been going on with the big picture of your cancer, it does save time. So you don’t actually have to repeat from the top. And I will say I’ve also watched people still and I caught myself a couple times where we still ask, what do you understand? And then we still repeat the whole story. And so I certainly encourage all of us to think like if they heard it, totally fine to move forward, but the other efficiency piece and I know all of us have been vital talk trained thinking about a headline in like a big picture. What is the big message? I always think about a headline is what is sort of the summary of the medical information and what is the impact on the future of this person’s health?   Knowing that we often are pretty good with the summary of the medical information but a little less good at the impact. I always find that that helps them better understand their big picture and be able to then share the same information with their loved ones. They could easily have that catchphrase or a two-liner that they can say, guess what? The oncologist has shared this with me. I think that’s so helpful when they’re thinking about their overall care and helps them inform their goals and priorities and helps us better understand their goals and priorities.  That concludes part one of our conversation on delivering serious news. In part two, we will continue the conversation on how the care team can prepare for delivering serious news. Useful resources and more. Thank you so much to all of our listeners for tuning into this episode of the ASCO Education Podcast. Speaker 1: Thank you for listening to this week’s episode. 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 elearningdotasco.org. Speaker 2: The purpose of this podcast is to educate and to inform. This is not a substitute for professional 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. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

In this Oncology, Etc. episode, Drs. Patrick Loehrer and David Johnson Speak with Drs. Lecia Sequist (Massachusetts General Hospital) and Melissa Dillmon (Harbin Clinic) on how ASCO’s Leadership Development Program (LDP) has taken them down varying paths, as well as the ways it has influenced their lives, careers, and the lives of those around them. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: education.asco.org | Contact Us Air Date: 2/1/22   TRANSCRIPT [MUSIC PLAYING] PAT LOEHRER: Hi, I'm Pat Loehrer. I'm director of the Center of Global Oncology here at Indiana University. DAVID JOHNSON: And hello. My name is David Johnson. I'm at UT Southwestern in Dallas, Texas. So Pat, we've got a couple of really great guests today. PAT LOEHRER: Yeah. I'm really excited. I've been looking forward to this. DAVID JOHNSON: So have I. Listen. Before we get started, I have a book I want to recommend to you. This one I got over the holidays and just finished it recently. It's called The Doctors Blackwell by Janice Nimura. So as many of our listeners know, Elizabeth Blackwell was the first female physician in America. Her sister Emily also followed her into the medical profession. Nimura really writes, I think, a fascinating biography about both ladies, particularly Elizabeth. And one point she made, and I think it's interesting, it's not really clear why Elizabeth went into medicine. Certainly at the point that she did in the mid-1800s wasn't a profession of great reputation at that time. And, in fact, Nimura describes Elizabeth as, quote, "lacking a caring instinct," which I thought was an interesting characterization of the first female physician. And she indicated that she was hardly a feminist. She was actually opposed to Women's Suffrage, for example. According to Nimura, she became a doctor largely just to show that she could. And then, really, the rest of her career I won't give away. The subplot is really quite interesting. I think you would find it most interesting to recommend to you and our listeners who have a particular interest in medical history. PAT LOEHRER: Actually, I've ordered the book. I can't wait to read it. DAVID JOHNSON: Excellent. PAT LOEHRER: I got a book for Christmas, Lyrics by Paul McCartney. And I read through that. That's fascinating, actually. So 158 of his songs were detailed and the backgrounds for it. So that was kind of fun. We're excited today because we're going to talk to a couple of graduates of our Leadership Development Program. That was a program of ASCO that was conceived a little over a decade ago. It's been, to my mind, one of the best programs that ASCO has done. It has taken younger faculty and oncologists from around the country, and Dave and I were among the first leaders of the program as mentors. I think that was one of the bigger mistakes ASCO has ever done. But despite that, we have a lot of fun. There were 12 graduates each year. They all had projects they presented to the board of directors. There were, if you will, classes and lectures throughout the year on leadership. And they all had projects. And for me, it was the best three years of my life, I think, through ASCO. It was just a lot of fun. And part of it was getting to know a lot of people, including Melissa and Lecia, who are with us today. Lecia is a Professor of Medicine at Harvard and Mass General Hospital. She did her medical school at Harvard, residency at Brigham and Women's Hospital, fellowship at Dana-Farber. She is currently the co-leader of the Cancer Risk Prevention and Early Detection Program at Dana-Farber and director-- I think I want to hear more about this-- she's the director of the Center for Innovation in Early Cancer Detection at MGH. Melissa, she went to Converse College in Spartanburg, South Carolina, went to medical school at Wake Forest. Then did her internship and residency at UAB. She did her fellowship at UAB. And she now serves as the Chairman of the Department of Oncology and the Board of Directors at the Harbin Clinic. And we're so excited to have both of you here. DAVID JOHNSON: Yeah. Very much so. And why don't we get started by just getting a little background information. Melissa, let's start with you. Can you tell us a little bit about how you got into medicine and, more specifically, why did you choose oncology? MELISSA DILLMON: That's a great question. I was a political science major at a women's college in South Carolina and was destined for the State Department. And we used to have January terms. And I mistakenly got put with-- and I don't think it's a mistake-- former graduate of Emigre Medical School, who is a medical oncologist in Greenville, South Carolina, for a six-week term and fell in love with medicine, fell in love with the ministry that he provided to his patients, and followed him to Bowman Gray and went back years later and told him thank you for changing my life. So that's how I got interested in medicine. I come from a long line of accountants and engineers. There is no person in my family in medicine. PAT LOEHRER: I was an engineer. Some of the best people in life are engineers. DAVID JOHNSON: I didn't know you drove a train. [CHUCKLES] PAT LOEHRER: Eat your heart out. DAVID JOHNSON: So Melissa, before you leave, I actually grew up very close to where you practice. How did you end up in Rome, Georgia? MELISSA DILLMON: Well, my dad and his twin are proud graduates of Georgia Tech. So he found me a job. And I said, well, I'm grown up. I was going to stay on faculty at UAB but came to Rome, Georgia and really was excited about the multispecialty group that I ended up joining. There's about 250 of us now. And kind of had the feeling of a university but in a small town. Kind of best of both worlds. Neither of my two daughters have gone to Georgia Tech. One of them is at Georgia. Just won that national championship. But my third one, we're hoping maybe she'll be the one that goes to Georgia Tech. PAT LOEHRER: So you stayed up and watched the game. I have to ask this, right? MELISSA DILLMON: I did. I stayed up to the very end. PAT LOEHRER: And so who are cheering for? Alabama or Georgia? MELISSA DILLMON: Definitely Georgia. PAT LOEHRER: Interesting. Good. Good. DAVID JOHNSON: And Lecia, why don't you tell us about your background and how you got interested in oncology. And let us know if MGH has a football team. [CHUCKLES] LECIA SEQUIST: Oh, sure. Thanks for having me here. This is going to be a fun conversation. So I grew up in the Midwest, in Michigan. But I've been on the East Coast now for the majority of my life. And when I was a resident, I was actually in a primary care track residency program, because I thought I wanted to be a primary care physician. And I really liked the idea of sticking with people, getting to know them over long periods of time, and kind of standing by them through the highs and the lows of their lives. Well, I was finding out in residency that primary care wasn't really like that. That was for television shows. People change primary care doctors and move around so much, it's rare that you actually do get to take care of people for a long time, at least in a big city. And I also found that, for me, primary care was a lot of asking people to do things they didn't want to do-- exercise, lose weight, stop smoking, do this, do that. And I always felt that I was at odds with my patients or nagging them. And then, when I would be in the hospital on oncology rotations, trying that out, I really felt like I was allied with my patients and not nagging them or pushing them, but really here we were together against this fight against cancer. And cancer was what we were fighting together. And I just fell in love with that. So much to the disappointment of the residency program that was really trying to get people to go into primary care, I said, I've got to be a specialist. And here I am. PAT LOEHRER: It's interesting, though, that you do risk reduction and prevention. So you're back to telling patients to lose weight and exercise again, you know? [CHUCKLES] LECIA SEQUIST: Yeah. I guess, in some ways that's true, although I'm not really taking care of primary care patients. But after spending a lot of years doing a more traditional medical oncology track of drug development and targeted therapies, the last five years I have switched my research over, kind of a midlife crisis situation, where I said I've got to do something different. I'm in a rut. And I started looking at new technologies for early detection. And I really enjoyed it because it's something different. For one thing, I just felt like I was in a rut. But it's really a way to be a lot more proactive with the community and to work on issues of social justice, thinking about cancer screening, and who has access and who doesn't, and what can we do better. So I'm really enjoying that in this phase of my career. PAT LOEHRER: Terrific. The four of us are linked because of this Leadership Development Program that the American Society of Clinical Oncology put together. And I think Dave and I are really curious whether, here it is many years later now. It's been almost 9 or 10 years later now. As you reflect on the LDP, what are some of the highlights? What did you learn about yourselves and was the program worthwhile for you? MELISSA DILLMON: Well, I'll start. I was part of the class, 2010-2011, best class ever. And it was the second class in the Leadership Development Program. I applied for the first year's class and didn't get it. And one of my friends and partners, a radiation oncologist, who was very involved in ASCO, encouraged me strongly. Said, don't give up. Try again. And I did. And it was instrumental in developing both my career within ASCO as well as pushing me to leadership positions in my own clinic and in my own state. And helped develop a lot of skills that have made me successful in pushing state legislative efforts. My political science background did not go away, just like her primary care roots. And so I think that the program also made friends with Pat and with Dave and with my co-classmates. And as the years have gone by, and I've gone to ASCO, when you see that LDP ribbon on somebody's tag, you immediately have a connection with them and know that you've been through a similar experience. So I think it's been really instrumental in developing my career. And I'm currently serving as a mentor for the leadership program. So I'm living your life 10 years ago, Pat and Dave, and it's great. DAVID JOHNSON: Oh, I'm sorry. PAT LOEHRER: Terrific. DAVID JOHNSON: [INAUDIBLE] LECIA SEQUIST: I would echo what Missy was saying about how much it's influenced my career. I was in the 2011 class. So I think the year after she was. And I also applied multiple times, and I always tell people who are thinking of applying that it often does take multiple attempts to get in and not to lose faith. The selection committee does like to see that persistence. So definitely apply more than once. I learned so much about what leadership is. I thought it was about being the best in a group of people. So then, being selected to have a certain title. And I just really learned so much during that year, that it doesn't really have anything to do with a title, although that can be a part of it for some people. But it's just more about a style, an approach to your profession, and that you can be a leader if you are the designated head or chief of something, but you can also be a leader if you don't have that designation. And there are many different styles and ways to lead and to help people to ultimately get a group to do the very best that they all can together. And the friends that I made that year from my co-classmates as well as you guys and Jamie, who are our leaders, are just lifelong friends and mentors. And you know, I think it really got me thinking seriously about my choices in my career too and not to just kind of cruise through a career and see what happened and where life took you, but to really plan and to chart your own course and to make sure to reevaluate. And if it's not going the way you want it to, to rechart and replan. DAVID JOHNSON: We had a bunch of different lectures on different topics. Was there one of the lectures or areas that was particularly beneficial to you? PAT LOEHRER: I can think of one. I'll start out by doing this. We threw this in the second year, just for the heck of it. We did this personality testing. And I thought it was fascinating because, in my group, there was a little bit of conflict going on with one of the people in my group. And I realized that we were both acting out our personalities. I like to look at the big picture, and he liked to just zoom in the middle one. And the other thing that I do remember is that we showed the profiles, and it turned out Dave and I were exactly opposite. And then we both said at the same time, we should be married. [CHUCKLES] MELISSA DILLMON: One lesson that stands out in my mind was the press preparation lesson that we received from Press Relations group at ASCO. And I think that was essential for developing skills with regards to preparing for difficult conversations and being able to redirect questions that were difficult. I use that as leader of the Government Relations Committee oftentimes. I will also say that the other lesson that stands out in my mind is conflict resolution because, at the time, I was not chair of my department and was having significant conflicts with the current chair of my department. And that lesson helped me to go back week after week and more constructively work towards a solution and then eventually became chair of that department. So I think those two lessons gave me lifelong skills that I've used in all my leadership roles. LECIA SEQUIST: Yes, it's amazing how 10 years later, we can still remember the specific lectures and specific comments that people made. I remember those that you were talking about Melissa, but yeah, before you had said yours, Pat, I was going to say the same thing, that personality test was extremely helpful. And I certainly don't remember all of the different initials of the personality types. But just to understand that concept that people have different emotional skills and blind spots that very much influence how they deal with others in the workplace. And to be able to think about that when you're having conflict with someone and think about how to take that into a strategy where you can kind of play to their strengths and understand where they're coming from, that was extremely helpful. And then, I also think that talking in small groups with our teams about specific problems we were having or obstacles that we were facing and getting advice from others on how to overcome them, that really started me on a recurrent mission to find friends who I could share that with outside of my institution, over the course of my career. I think that was a real exercise in how valuable that could be. It's so critical to have peer mentors that you can talk to and strategize with and get advice about how to handle something that you're struggling with at work and have people that aren't in the same room full of people or aren't living in it. So they're a little bit more objective. DAVID JOHNSON: Let me ask a question of the two of you. Do you think your home institutions in your case, Lecia, MGH and in your case, Missy, Harbin Clinic, valued that training that you received? Did they recognize it as something that was worth the time that you spent or do you think it just something that happened and they didn't really take notice? MELISSA DILLMON: I learned in LDP that institutions don't love you back. PAT LOEHRER: They don't love you to begin with. Joe Simone. Joe Simone. DAVID JOHNSON: So I take that as a no. Your institution really said, eh, OK, great. We're glad you did it, but so what? LECIA SEQUIST: I wouldn't say that. I don't know that they said, so what? I just, I'm not sure that they-- there was no rolling out the red carpet, thank goodness you did this. But I do think it's had an institutional impact in that I have since encouraged other people to apply from my institution. And I think that only strengthens the institution, to have multiple people going through that program. MELISSA DILLMON: So my clinic, being private practice, when I take time out, it is just a cut from my salary. There's no support given from the institution. But in order to be in positions of leadership, department chair or on the board of directors, which I later was elected to of the clinic, you have to have completed a leadership development program. And the clinic will pay for you to go do those things. But my participation in Leadership Development Program met all those criteria. So my clinic highly values professional development classes or meetings or programs and encourages that. Even if there's no financial support necessarily, it is encouraged, if you want to assume positions of leadership within our clinic. And so I think that it's important for institutions, whether they're private practice or university, to recognize the benefits that come from participation in a program like this. And it was interesting as a mentor this year, we did a personality test, but this time they did an interesting look at what our priorities, our top five priorities or values are. I think it was values. And it was a list of 300 things basically you go through. And you listed your top five values. And then you listed the values of your institution or employer. And then you wanted to look at, did they match? And did your university value what you value? And that was a really interesting exercise to go through because a lot of these young leaders who are taking their time out to do this program did not feel that support necessarily for them seeking out this program. PAT LOEHRER: It's no coincidence that Dave and I asked both of you to join because you both come from different places, if you will. And I think, Melissa, you've just been a rock star in terms of the community practices and so many things that you have done in the leadership roles. And Melissa's, you can't get any more prestigious in being in one of the Boston medical schools and particularly at Mass General. But the other reason we wanted to have you come in is to talk a little bit about your perspective as women and women in leadership roles. And if you could maybe share a little bit about your thoughts and perspectives of gender leadership and what you have noticed in men in leadership roles and women and what lessons you might give to other people, particularly other women in this capacity. MELISSA DILLMON: Well, I think we both were trained in a day. And I might be speaking for you, but when there were, at least here at the institutions where I trained, not that many women in internal medicine. Medical school was probably 45% female by the time I was in medical school. But when you look at the faculty of those medical schools that I went to and trained at, there were very few women in positions of leadership. And so there weren't very many role models. My dean of students at Wake Forest was a female nephrologist. And so she was a huge role model for me. And then I went to UAB, and I remember being asked in my interview, are you OK with being in a male-dominated program? Because you will be in a male-dominated program. I think there were 45 of us in my intern class, and eight of us were female. And I said, that's fine. But I had gone to a women's college, where obviously there were only women leading. So it was a big change for me to go back into a situation where I had to assert my unique female leadership qualities, which are different, and still use those in an effective way to lead. Right now, I'm serving as a mentor also for a small liberal arts college, primarily those interested in going into medicine or nursing, and usually most of those have been female. And so it's been a really great opportunity, because I've had very few mentors who were female, who were positive role models for me. So I think Leadership Development Program, one of the things they taught me was to go back and say thank you to your leaders and to be a leader for others. And specifically, as a female leader, I think that has been an important call for me. After leaving Leadership Development Program, I went back and ran for the board of my clinic as the first female to be on my board. My clinic was started in the 1860s, I think right after the Civil War, and I'm still the only female on that board. And I feel that it's important for me to stay there or to promote up more females within my clinic to be on that board because I think that having a diverse board helps in bringing different skill sets to the table. So I think Leadership Development Program gave me that courage to step up. LECIA SEQUIST: That's inspiring. Congratulations on being the first woman and may there be more soon. Yeah. I don't know that I've felt that I was in as much of a male-dominated field up in Boston. But certainly, leadership in my hospital and in my cancer center has been more male-dominated. And I think as I'm getting older now, I definitely appreciate-- of course, every individual has different leadership style. So you can't just paint a broad brush and say men are this type of leader and women are that type of leader. Everyone's a little bit different. But in general, I think women do tend to have a different leadership style and one that is maybe, present company not included, one that's less talking and more listening. And I think, when I was younger and trying to become a leader, I really felt out of peer pressure that I needed to talk more and sort of demonstrate more what a good leader I could be or what great thoughts I had. And I've really come to embrace a more listening type of leadership, which I have been happy to say that younger women that I work with have come up to me privately and thanked me for. And so I do think it's important to have all different types of role models for our junior faculty and all different types of styles, sort of on display and doing their best so that people can find something that matches with their own unique style to emulate. PAT LOEHRER: One of the lessons I learned a long time ago from someone, and I loved it, a great leader is one that changes the conversation. And to your point of listening, but it's really changing the conversation, deflecting it around it so that other people are talking. But you have a little role in moving that around. And I always liked that. MELISSA DILLMON: Today, I was listening to the National Press Conference, and I heard a definition of leadership that disturbed me. And I thought, I don't think that's my definition of leadership. So I think that defining what your type of leadership style is, is something that leadership development helped me with. And then, once I knew what my leadership style was, then using those skills to pull together a team and achieve a goal, a common goal, not the description of leadership today, which was pushing something up a mountain and rolling over boulders and doing whatever you had to do to get your way. I thought, well, that's not leadership, not my leadership. So I think that that was something that Leadership Development Program help me do is identify what my leadership style is and what kind of leader I want to be. DAVID JOHNSON: So I want to follow up on a point that both of you are making in a slightly different way. And that is, who are your role models? I mean, apart from Pat and me, but who are your role models? [CHUCKLES] LECIA SEQUIST: I've had lots of role models over the years, and I think at the beginning, my role models were really people that I wanted to emulate and be just like them. And that probably started with Tom Lynch, who was my initial research mentor when I started in lung cancer. And a lot of it was just the way he was with patients. I wanted to have that ability to make a patient feel just right at home from the first minute they walked in the door, which Tom is a master at. But over time, I think my mentors or my heroes have more become people that are different than me. And I'm not trying to be like them. But I appreciate the ways in which they lead or in which they conduct something, like balancing their home life and their professional life in a way that's just different but I appreciate. And that, in lung cancer, I would say another real big influence on my career has been Heather Wakely. She really has been my main female role model in my career. And she's given so much of her time to me and to so many to kind of sit and have personal talks and pep talks and strategies about what we're doing in our home institutions. DAVID JOHNSON: Missy, what about you? MELISSA DILLMON: So I would say from a professional standpoint, someone I respect and see as a mentor is actually now the female CEO of my clinic, who has been with my clinic for 20 years and worked her way up. And I think that's because she has retained her femininity, but she is recognized as a tiger that no hospital or other clinic wants to make mad. So she has a way of leading and listening that is unique. And I have learned a lot from her over the years and watched her rise in her leadership skills as I have alongside of her. And then, I will say from a personal perspective, one of the books I have enjoyed reading recently really talks a lot about servant leadership. And so I've really tried to identify servant leaders in my community and why it is that they're able to weather the storms of the last couple of years, for instance, and why their teams rally behind them and support them. And they're successful. And my husband is a restaurant owner times three, opening two of those, one right before COVID and one during COVID and yet has been able to mobilize a team. And that's because he's a servant leader that will get back in the kitchen and make pastry cream if that's what needs to be done or make reservations. And so I think during the last two years, what I have learned from that is to be a servant leader in the tough times has really helped rally my team and my clinic to be better and to continue to work, despite the challenges for our patients, for the bigger goal. PAT LOEHRER: Love it. We recently had a guy give a talk here at IU, and the lecture was on being a visionary leader. And to be honest, it was fine. It was good, but being a servant leader and being part of a group is more important than being the one right up in front. And it's good to be a follower too as a leader. So I really appreciate those comments. Just in a couple of sentences, I don't know if you guys could do this and reflect a little bit about your younger self. Say you're 21, and you could give yourself some advice now, what would those pieces of advice be? LECIA SEQUIST: I think one thing, and that's the common thread I've heard among a lot of more senior people in medicine, or in any profession probably, is that the things that you think are disappointments at the time often turn out to be some of the greatest opportunities that you're faced with. You plan and you think things are going to go a certain way, and then something doesn't work out, and you're very disappointed. But it's usually that process of how you deal with that disappointment that actually brings so much opportunity back to you. You can't see it at the moment. All you see is the disappointment. But I think that's a big lesson. PAT LOEHRER: Terrific. MELISSA DILLMON: So kind of similar to that, Lecia, doing our personality test this time, I wish I had done that same exact test 10 years ago, because I'd like to see what my leadership personality was 10 years ago versus now. I would not have scored as high in certain areas that I think I do now. And I think that one of the biggest things I have learned is, I'm very much a person of tradition. And I like things to continue the way I expect them, and I like things to be planned and done in medical school in four years, done with fellowship. So I like a regimen and a routine. And I have learned over the years to be comfortable with change. And I wish I had learned that earlier and to be open to change and listening to new ideas. I think that probably for the first few years of my practice and training, I was very much, this is the way it's done. And I think that that expressive part of my leadership had not developed yet. And I think that being open to change and looking at things in new ways, I wish I had learned that earlier. DAVID JOHNSON: So we only have a few minutes left. And what we have done in previous episodes, we like to ask our guests to tell us the book they've read recently or maybe a documentary or something they've watched recently that they would recommend to our listeners. LECIA SEQUIST: I really enjoyed the book The Four Winds by Kristin Hannah. That is a historical fiction about the Great Depression and the Dust Bowl and the migration of farmers from the Central Plains out to the West. And it was a really captivating book with a female protagonist. I enjoyed it quite a bit. MELISSA DILLMON: It's funny. I read that one just a few months ago. I love historical fiction, but I would say recently, and I know it's not a new book, Andre Agassi's Open, his autobiography, I found fascinating. I love sports, but it was very interesting to me to see how someone who's thrown into the limelight at a very early age and the pressure put on him by his parents and how that affected the course of his life. I found it a fascinating book and very insightful. And I like to play tennis, but I'm not a tennis player. But I found it interesting as a parent, who's got several sports-minded children, it gave me some lessons about parenting and how to just raise your children and where the focus should be. DAVID JOHNSON: Both my wife and daughter had been tennis players. I'm sure they would both love reading that book. Thanks for that recommendation. LECIA SEQUIST: It's a great book. DAVID JOHNSON: Well, that's really all the time we have for today. And Pat and I want to thank both of you, Missy and Lecia, for joining us. It's been a terrific conversation. Thank you so much for what you do. You're both, in our minds, fantastic leaders. You were when you arrived, and you certainly have been ever since. So thanks so much for that. I want to thank all of our listeners for tuning in. This is Oncology, Et Cetera an ASCO Educational Podcast. And we really have talked about anything and everything. And we'd like to continue to do so. So if you have an idea for a topic or a guest, please email us at education@asco.org. Thanks again for tuning in. And Pat, I just wanted you know I've ordered a chicken and an egg from Amazon. [CHUCKLES] PAT LOEHRER: It's because you couldn't quite make up your mind which was going to come first. I love it. I love it. You're the best. Thanks for doing this. And Dave, it's good to see you, as always. Take care. DAVID JOHNSON: Thank you so much. We really, really appreciate it. LECIA SEQUIST: Thank you. MELISSA DILLMON: Great to speak with you. Bye. [MUSIC PLAYING]   SPEAKER 1: Thank you for listening to this week's episode. 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. [MUSIC PLAYING]   The purpose of this podcast is to educate and to inform. This is not a substitute for professional 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. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING]  

How do you talk to patients about medicinal cannabis? Dr. Ashley Glode (University of Colorado) moderates a discussion on effectiveness and safety, misconceptions and more. Featuring Drs. Ilana Braun (Dana-Farber Cancer Institute), Daniel Bowles (University of Colorado), and Kent Hutchison (University of Colorado). Subscribe: Apple Podcasts, Google Podcasts | Additional resources: education.asco.org | Contact Us Air Date: 1/19/22   TRANSCRIPT ASHLEY GLODE: Hello, and welcome to ASCO Education's podcast on medical cannabis, also referred to as medical marijuana. My name is Ashley Glode, and I am an associate professor with the University of Colorado School of Pharmacy. It's my pleasure to introduce our three guest speakers Dr. Ilana Braun is chief of the division of adult psychosocial oncology at Dana-Farber Cancer Institute, and an assistant professor of psychiatry at Harvard Medical School. Dr. Daniel Bowles is an associate professor of Medical Oncology at the University of Colorado. We're also joined by Dr. Kent Hutchison, a professor of psychology and neuroscience at the University of Colorado Institute of Cognitive Science. Let's start with a simple but fundamental question. What is medical cannabis or medical marijuana? ILANA BRAUN: So Ashley, I think that's such a great first question. I think of medicinal cannabis as herbal nonpharmaceutical cannabis products that patients use for medicinal purposes. And typically they're recommended by a physician in compliance with state law. DANIEL BOWLES: Dr. Braun makes a really good point. And I think it's important to know when patients are referring to medical cannabis, there's a wide variety of different things they could be referring to. Sometimes they would be referring to smoked herbal products, but there are also edibles, tinctures, ointments, creams, all sorts of herbal-based products that people use and call medical cannabis. And then there are also the components that make up medical cannabis-- largely, the cannabinoids. And I think the big ones people think about are THC and CBD. And sometimes those are used in their own special way. So I think that it's important for us as providers to be able to ask our patients, what is it that you mean when you say, I'm using medical cannabis? ILANA BRAUN: I think that's such a great point. And I will add I think it's also important to remember that when you offer a medicinal cannabis card to a patient, you're giving them license in most states to access any number of products. It's not an insurmountable challenge, but it's a whole new world for traditional prescribers who are used to writing a prescription and defining what is the active ingredient, how often a patient will take the medicine, by what means. DANIEL BOWLES: I think the other thing we need to be very aware of, as hopefully people are listening to this across the country and elsewhere, is the laws vary wildly from jurisdiction to jurisdiction about what consists of medical cannabis, who is allowed to use it, and in what quantities. So I think it's really important that as we learn about these and we think about these, we think about how they apply to any of our specific situations in which we live in practice. KENT HUTCHISON: So it's interesting-- just follow up on what Dr. Braun and Dr. Bowles, what they're saying, those two words-- right-- medical and cannabis. I think the medical part is somewhat easier because it can refer to the reason the person is using. Are they using for medical reasons are they using for recreational reasons, even though that's a blur? But the cannabis part I think is what's really complicated. And this is what Dan was getting at. All the different products, all the different cannabinoids, I mean all the different bioactive terpenes and everything else in the material, all different forms of administration. That is where it gets super complicated to really define what that is. And then of course, there's so little research we don't really know what all those constituents do. ASHLEY GLODE: Now that we kind of have a little bit of familiarity with medical cannabis, can you comment on adult use cannabis and what that might mean for a patient? ILANA BRAUN: Ashley, I think it's a really good question. And in some of the early research I did to try to understand where medicinal ended and adult use began, or adult use ended and medicinal began, I began to discover a theme that emerged, which is they sort of blend into each other often. In other words, some of the oncologists that I spoke to believed that it was not such a bad thing for a patient with serious illness, and pain, and many other symptoms to have a sense of high or well-being. And conversely, when I spoke to patients using cannabis, sometimes a cancer patient used medicinal cannabis for enjoyment, and sometimes they used it for symptom management, and sometimes they used it for both. And so I think it is somewhat of a slippery slope between the two. Would you agree? DANIEL BOWLES: I think there are definitely blurred lines between the two. I think that the advantages of what most states would recognize as medicinal cannabis is usually they're less expensive, patients can use them in larger quantities. There are certain advantages. But there's also paperwork that goes along with medicinal cannabis that some patients don't feel comfortable with. Or particularly I think when you have a patient who's interested in trying cannabis or a cannabinoid for the first time, they might not want to go through all the extra steps required getting that medical marijuana card, whereas adult use, I think people feel more comfortable, at least in my state, sometimes walking into a dispensary to discuss the options with people who work at the dispensary and then get it from more of an adult use or recreational cannabis initially. And then if that's something that they find helpful for their symptom management, to then take those extra steps and try to get a medicinal card. ILANA BRAUN: I agree with Dr. Bowles that the target symptoms or the target effect is often similar and access can differ. KENT HUTCHISON: Yeah. Just to chime in, I agree. I agree also. It's definitely-- the lines get blurred. The recreational user might also appreciate-- for example, college students, I hear them say a lot of times that they appreciate some of the anxiety-reducing aspects-- right-- even though they're not necessarily a person who has an anxiety disorder. And then of course, patients appreciate a slight increase in euphoria or positive affect, and what does that mean? Is I mean they're also using for recreational reasons? Or is that completely, I guess, legitimate? On the other hand, there are sometimes I feel like when-- especially on the recreational side-- when people are using for the more psychological effects, the sort of psychotropic effects, I know sometimes the medical patients refer to that as being a little bit loopy as a side effect. So I feel like there's definitely some blurred lines. And maybe there are some places where we can think about in perhaps in a less blurred kind of way. ASHLEY GLODE: How often do you guys have a patient ask you about medical cannabis? And what are the most common questions they might have for you? ILANA BRAUN: In my psycho-oncology practice, patients frequently tell me they're using cannabis, often with good effect and minimal side effects for polysymptom management-- for instance to address nausea, or pain, or poor appetite, or sleep, or mood, or quality of life. But they don't ask me a lot of questions. For instance, one of my longest-standing patients. A man with metastatic cancer and gastroparesis. Vaporizes cannabis before meals to keep his weight up. And many of my patients also use cannabis as cancer-directed therapy. And for these patients, side effects can sometimes be more pronounced. For instance, I have a lovely patient with metastatic cancer who follows a Rick Simpson protocol. So what is that? That's an online recipe marketed with an antineoplastic claim. And so this patient targets hundreds milligrams of cannabinoids daily. And with such high cannabinoid doses, she sometimes feels spicy, or out of it, as she describes it. And then I had another patient who targeted high daily doses and developed a debilitating nausea and vomiting that was initially diagnosed as chemotherapy-induced nausea vomiting because it was so hard to tease out in the setting of so many medicinal agents, what was what. But the symptoms resolved completely within weeks of the cannabinoids being halted. And so as I mentioned, what's notable about all three of these patients, and many of the others I see, is that they are quite open with their oncology teams and me about their medicinal cannabis use. But they don't seem to rely me or other members of their oncology team for their therapeutic advice . We insert ourselves when we see potential harm, but much of the decision-making seems to be made-- I don't know in the naturopath's office, at the dispensary counter, or by trial and error. And this anecdotal experience in my practice is borne out in my research findings as well. Patients are just not getting the bulk of their cannabis therapeutics information from their medical teams. DANIEL BOWLES: In my clinical practice, I am asked about cannabis or cannabinoids a fair, amount often in the context that Dr. Braun is describing, where a patient is coming in and they're already using a cannabinoid or they are planning on doing it and they just want my opinion. And I think unlike talking about more conventional cancer-directed therapies where they really rely, I think, on their medical team for information and guidance, we are often more a supplement I think in terms of information. In terms of the patients who come to ask me about cannabis or let me know that they're using cannabis, it's a very wide selection of people. I see young people, old people talking about it, men, women, a variety of different malignancies. So there really is a lot of usage or are thought about usage of cannabis or cannabinoids amongst our cancer patients. I think if you look at the studies, they'll tell us that depending on where we're working, anywhere between 20% to 60% of patients have used cannabis in the last year to help manage some sort of cancer-related symptoms. And I think the other thing that is notable is you'll find people asking about cannabis or cannabinoids who I think we might not have otherwise expected. So for instance, Just this past week, I had a patient with anaplastic thyroid cancer in his 70s, and his daughter was wondering whether he could try CBD to help with his sleep and anxiety. She wanted to make sure that it wasn't going to interact with this cancer therapies. And I appreciated her bringing it up, and we could have a frank discussion about the pluses and minuses of it, just like we might any other therapeutic intervention. So I think that particularly as the laws have changed across the country, more and more people are willing to tell us that they're trying cannabinoids and cannabis than maybe would have even 10 or 15 years ago. KENT HUTCHISON: I think in an ideal world, patients would be talking a lot more with their physicians about this topic. And I think unfortunately that a lot of people do get their information from dispensaries. From the media, from social media, from their kids, and from whoever. And I think that's something that I hope will change in the future. DANIEL BOWLES: In terms of questions that I'm often asked, I'll be asked if it's going to interact with their cancer treatments, in terms of making their medications more or less effective. I do get questions about how I think their cannabis use might affect some of their symptoms. I get questions about other drug-drug interactions-- let's say, interactions with opiates, or benzodiazepines, or some of these other medications that a lot of our patients are on. ASHLEY GLODE: In a recent survey 80% of medical oncologists who discussed medical cannabis with their patients, 50% recommended it in the past year, but only 30% felt knowledgeable enough to make recommendations. What do you guys think needs to be done to address this knowledge gap? And what resources do clinicians have to get and stay informed? DANIEL BOWLES: So I'm a big fan of the NCI's PDQ as a great resource. It has a fairly objective information about cannabis and cancer specifically. So I think that's a nice reference for people who are interested in getting an initial overview on the topic. I think there are also a number of different educational programs. I know the University of Colorado, for instance, has a Cannabis Science Master's and also a certificate program. So there are courses available for people who want to educate themselves more on this topic. ILANA BRAUN: Yeah. I guess when I think about what needs to be done, I think that cannabis needs to become a routine part of medical training curricula and CME programs. I think that a federal funding for high-quality clinical trials and a loosening of federal restrictions on accessing study drug were to occur, that would be really a big boon for the medical community. And my colleagues on this podcast I know are doing some very creative pragmatic clinical trials naturalistic studying what is happening in the field. And I am doing clinical trials using an FDA-approved version of cannabinoids. But it's still very hard to study whole-plant cannabis in a form that is sort of a standardized trial drug in a cancer patient. And then when I think about where I would begin to read, I don't think there is a single source, unfortunately. But a great place to start reading is actually a project that Dr. Hutchinson was a part of, which was an expert panel that was assembled by the National Institute of Science Engineering and Medicine in 2017. And they produced a monograph on the health effects of cannabis and cannabinoids. And it's several hundred pages long, including sections devoted just to oncology. So in other words, there is scientific evidence to evaluate, and it's sizable. DANIEL BOWLES: The Austrian Center for Cannabinoid Clinical and Research Excellence also is a helpful resource. One of the nice things about that is they actually give some dosing suggestions or ideas for people who really don't quite know where to start. Right now, there aren't a lot of people in that position to say, here's how it should be done. Here's how it gets dosed. Here are the data to support those decisions. And so the folks in the next level of training don't learn it in the same way that we have learned how to prescribe other medications. And they can't then lay it down. So because the data are scant, in some respects, and particularly for herbal products that So. Many of our patients are using, I think it falls outside the medical model that we've all become so used to using to learn how to take care of patients. And I think that's one reason that so many oncology providers feel interested in learning more about this topic, but don't feel comfortable giving patients guidance on how to use them. KENT HUTCHISON: So both Dr. Braun and Dr. Bowles identified some of the key resources out there. And certainly the training issues that Dr. Bowles just talked about are important. And I do want to emphasize the one thing that Dr. Braun mentioned, which is basically that we do-- we lack research and we lack data on some key important issues, like dosing, for example. What dose is effective? So cannabidiol has been out there for a long time, but what dose is effective for what? We don't know, right? So we definitely lack research. And there are definitely obstacles to doing that research. ASHLEY GLODE: So you guys brought up some good points about there being a lack of data, but also there is some evidence. So what is the current research and evidence on the efficacy of medical cannabis for management of cancer symptoms and cancer pain, specifically? DANIEL BOWLES: So there was a really nice review article that just came out in the BMJ looking at cannabis and cannabinoids, not specific to cancer pain, but including cancer pain. And what they found-- they looked at different preparations from herbal products-- smoked herbal products, oral agents-- cannabinoids, more specifically. They found there is a modest, but a real improvement in pain in patients or research subjects treated with cannabinoids versus those usually typically treated with placebo. In particular, the data are supported in neuropathic pain, I'd say more so than the other pains. I think the data are less compelling with regards to many of the other symptoms that people often use cannabinoids for, such as sleep, anxiety, appetite, things along those lines. ILANA BRAUN: So I'll tell you a little bit about how I think about the evidence base in oncology for cannabis use. So I'll preface this with two points. The first is that, as I mentioned, cannabis products tend not to be one active ingredient, but hundreds of active ingredients-- cannabinoids, phenols, terpenes, they all have bioactivity. And they don't work individually, they work through complicated synergistic and inhibitory interactions that have been termed entourage effects. So I don't think one can easily extrapolate from clinical trials of, say, purified THC, to understand whole-plant cannabis' activity in the body and how it might perform in humans. And then the other point I'll make is that when I think about the types of clinical evidence that we as clinicians hold dearest, it's clinical trials of our agent of interest in our population of interest. So cancer patients using whole-plant full-spectrum cannabis that they would access at a dispensary or grow in their own home. With this in mind, I believe the strongest evidence, randomized double-blind placebo controlled trials of whole-plant cannabis and oncology populations begins to support its utility for chemotherapy-induced nausea and vomiting. So there have been a few studies that have looked at this. But just in 2020, the most recent is a study by Grimison, et al. It was a multicenter randomized double-blind placebo controlled crossover trial comparing cannabis extract. And I think the extract they use was a 1 to 1 THC to CBD ratio versus a placebo in patients with refractory chemotherapy-induced nausea and vomiting. And what they found was that with active drug, there was a complete response in 25% of participants versus only 14% with the placebo. And although a third of participants experienced additional side effects with the active drug-- so remember, this was a crossover trial, so they saw both arms-- 80% preferred cannabis to the placebo medication. So that's clinical trials of cannabis and cancer. But if we expand the base of the pyramid of acceptable evidence to include high-quality clinical trials for health conditions other than cancer and extrapolate back, then I agree fully with Dr. Bowles that there's a growing body of evidence that cannabis may be beneficial in pain management. And there have been many clinical trials done in this arena, and they span myriad pain syndromes, including diabetic neuropathy, post-surgical pain, MS pain, sickle cell pain. And so it does seem like cannabis works for pain management in several other illness models, so we could extrapolate back and hope that it works in cancer pain. And then there is a small body of evidence with nabiximols, which is a pharmaceutical that has a 1 to 1 THC to CBD ratio. And it's a sublingual metered dose spray. And it has been trialed for opioid-resistant cancer pain. And this is not as a single agent, but as an adjuvant to opioids. In early trials, two times as many participants in the active arm as compared to the placebo arm demonstrated a 30% pain reduction. And for the pain specialists who are listening, they will know that is a substantial pain reduction. But then, additional studies fail to meet primary endpoints. I think there were three clinical trials that followed. Nabiximols was found to be safe and effective by some secondary measures, but the FDA opted not to approve nabiximols for cancer pain. So I think there's some suggestion of effect, but there's some smoke, but no fire-- no pun intended. DANIEL BOWLES: I think many of the studies that have been done looking at cannabis-- or cannabinoids-- have been compared to placebo or they've been crossover. And I would say fairly consistently, there is some improvement in pain scores with the cannabis products versus placebo kind of across a wide variety of disease spectrums with regards to pain. I think one of the other questions that a lot of people have asked is, can you decrease people's opiate usage using cannabis? As we know, there's a huge epidemic of opiate misuse in the United States of America right now. And I think many people are looking for ways to decrease opiate usage. There was a nice study done from Minnesota in conjunction with the Minnesota dispensaries-- or state marijuana program-- where some researchers randomized people to starting kind of herbal cannabis products early in their study or three months into their study. So it was kind of a built-in control. And they looked at opiate usage rates, pain scores, quality of life scores, et cetera. What they found is there, again, was some improvement in pain control overall in the cannabis users. However, it did not equate to a decrease in opiate usage. So I think that it's an open question that I think a lot of people want to know the answers to before they start recommending or incorporating cannabis or cannabinoids more widely into their practice. KENT HUTCHISON: It's certainly a complicated issue, in some ways, right? Because the research which is summarized very nicely by both Dr. Braun and Dr. Bowles, it is suggested, but not overwhelming, by any stretch, right? It's not clear-cut. And I think that one of the big issues here we talked about the very beginning is how complicated this cannabis thing is. and Dr. Braun alluded to this also, that there are obviously many different formulations, many potentially active constituents in cannabis. And so what has mostly been studied so far is either synthetic versions of THC or nabiximols, which is probably the closest thing to what some people are using. So I think the jury's still out, for sure. And I think hopefully at some point, what will happen is that some of the products that are actually being used by people-- because most people aren't using nabiximols, most people are not using THC only, hopefully there'll be some trials of the things that people are actually using out there in the real world that will tell us something more about whether it's effective or not. And maybe even more specifically, which constituents-- which parts, together are most effective with respect to pain. DANIEL BOWLES: I think one of the other topics that some of my colleagues have alluded to already is not just cannabis' role in symptom management. I think pain is often what people think of, and people are using it for chemo-induced nausea and vomiting, anxiety, sleep, appetite, but a fair number of patients are also using cannabis or cannabinoids with the hopes that it is going to treat their cancer like a chemotherapy or an immunotherapy may. And oftentimes, patients will point to preclinical studies looking at oftentimes very high doses of THC or CBD that might show tumor cell death or tumor reduction in test tubes. And I spent a fair amount of time-- and I know some of my colleagues spent a fair amount of time-- talking with patients about how it's a big step between cannabis or cannabinoids working to slow cancer growth in a test tube, to working in an animal system, to working in people. ASHLEY GLODE: So what are the most important considerations clinicians should keep in mind before recommending medical cannabis to patients with cancer? DANIEL BOWLES: We should be asking why they want to use cannabinoids. I think just like we might any other medication that people are thinking about trying-- or herbal product that people are thinking about trying-- I think we need to ask why they're interested in using these products. So is it for symptom management? Is it for some of the ancillary side effects of cannabinoids or cannabis? Why are they wanting to use it? And I think trying to incorporate that more than into the medical model, I ask my patients, hey, if you're using this particular product, do you feel like it's doing what you intended it for it to do? If it is and it's legal in your state, great. Do it as you feel fit. If it's not meeting your goals, if it's not helping with the pain, or if it's not helping with the anxiety, or it's not helping with the nausea and vomiting, maybe we should rethink whether we would use it. Just as if I was prescribing more conventional anti-nausea medication and you didn't think it was working, we wouldn't keep using it. So I think that's a really important thing to keep in mind. I think the other thing to know from a safety standpoint is, who else is in the household? We have a psychiatrist on the call with us today. I think there is an ample amount of data that cannabis is not safe for young people. It's not safe for growing brains. And I think we need to make sure, just as we would want people's opiates to be secured, that their cannabinoids and cannabis products are secured as well, from those who do not want to use them. ILANA BRAUN: And the thing I would keep in mind is that in most states, giving patients a medicinal cannabis card is allowing them to access any number of products with different ratios of active ingredients, delivery mechanisms, onset of action, potencies. And if you don't discuss all of these issues with your patients, these are things that they will decide at the dispensary counter, or by discussing with friends and family, or by trial and error. And I think it's really important that we clinicians guide this narrative. ASHLEY GLODE: So what kinds of patients are not good candidates for medical cannabis? DANIEL BOWLES: I would not recommend medical cannabis for people who can't meet some of the criteria we already discussed. So people who can't keep it safe in their households or have concerns about diversion in their own households. Those are people who I think would not be great candidates for medicinal cannabis or cannabinoids. ILANA BRAUN: As the psychiatrist on the call, I would add that I worry for people with a strong history of psychosis, or currently psychotic, or with a strong family history of psychosis. And perhaps those severely immunocompromised, since there is evidence of fungal and mold contamination in some cannabis products. DANIEL BOWLES: The other group of people I discussed this with are patients on immunotherapies. One of the ways that cannabis may be effective in some of the symptoms we discussed is it's an anti-inflammatory agent. One of the ways it could be detrimental for patients on immunotherapies is that it's an anti-inflammatory agent. There is one small study that suggested that patients might have worse responses to immunotherapy who are cannabis users versus those who are not. So that is a conversation I like to have, just so patients feel like they can be informed. I think lastly, cannabis even for people with medical cards, is not free. So there can be a financial burden for people who are using it. So that's something that I'll often bring up with people as well. KENT HUTCHISON: One thing I would add to this would be history of a substance use disorder might also be a consideration here as well. Mainly because you don't know what the person is going to get, and it could be something that lends itself to relapse or encourages a problem. So I would add that to list. ILANA BRAUN: And I would second what Dr. Bowles said about the financial challenges of using cannabis regularly medicinally. It's not something that's covered by insurance, either. So these are out-of-pocket expenses, and they can add up fast, particularly for patients in the oncology space using it for antineoplastic therapy. ASHLEY GLODE: So is there a concern about drug-drug interactions for patients currently undergoing active cancer treatment? DANIEL BOWLES: There are some data that there can be drug-drug interactions with cannabis and certain agents. In particular, cannabidiol, or CBD, is a CYP3A4 inhibitor. And there are a lot of drugs that are metabolized through that particular system. So I think that that's the clinical relevance of those interactions, I think, is sometimes unknown. But that is another topic that I do think we need to make sure we bring up with our patients. ASHLEY GLODE: Thank you. Yeah. So a lot of what we'll do is from a drug interaction perspective, use the FDA-approved products that we have available to run through a drug interaction checker, like Dr. Bowles mentioned. So we'll use dronabinol as the THC-based product and epidiolex as the CBD-based product. There's also some resources, such as natural Medicines Database. And some of the pharmacy programs that we use, you can actually put in marijuana or cannabis as a drug and run drug interaction checks. So there's multiple potential interactions, like he mentioned, through the immune system. But through the cytochrome P450 pathway, cannabis has been shown in some instances to be an inhibitor, sometimes an inducer of certain enzymes, as well as a substrate. So it's really important to work with your pharmacy colleagues to run through different potential interactions that may be present. ILANA BRAUN: I'll just add one thing, just in case that's helpful. I mentioned earlier in the episode that I had a patient who used cannabis as an antineoplastic drug, and targeted very high doses and developed a terrible nausea and vomiting. And when she stopped, so did the nausea and vomiting, even though her chemotherapeutic continued. And I, to this day, don't know if that was a cyclic nausea and vomiting syndrome, which has been known to plague some heavy cannabis users, or whether drug-drug interactions led to her high-dose cannabis triggering high blood concentrations of her cancer-directed therapy at the time. And so I think that drug-drug interactions do need to be carefully weighed. ASHLEY GLODE: So wrapping up, has the medical community stance on medical marijuana shifted in recent years with legalization in many states? ILANA BRAUN: I don't think we know the answer to this, about how sentiment has shifted because there aren't longitudinal studies that I know of examining this question. But we need some. And one could imagine that as medicinal cannabis becomes are commonplace, providers are increasingly confronted with questions about how to guide care and the desire for high-quality clinical trials and in-depth cannabis therapeutics trainings increases-- and as one piece of evidence for this, at the end of 2020 the National Cancer Institute held a first-in-kind four-day conference at the intersection of cannabis and cancer. And so I'm hopeful that grant opportunities will follow from that. DANIEL BOWLES: I think overall there has been more willingness to discuss cannabis in the context of patient care in the last decade. A couple of ways that I see this is I much more frequently see cannabis use described not necessarily in the drug history, or in the social history, but in the medical history, or in their medications, if they're using it for medical or therapeutic purposes. I think the other place that I've noticed cannabis usage become a bit more mainstream is in the clinical trial setting-- not in clinical trials of cannabis, but one of the things that many of us do is clinical trials of new drugs. And very frequently, 10 years ago we ran into trouble trying to get our patients who were using cannabis products for cancer symptom control onto these clinical trials because of potential drug-drug interactions, or just the fear of the unknown. And I feel like we run into that less commonly now. KENT HUTCHISON: I think it's also worth pointing out that there have been more and more podcasts like this one, right? So to the credit of this organization, I think we are seeing some change. I just wanted to highlight that. And I compliment everyone here for putting us together and putting it out there. ASHLEY GLODE: All right. Well, thank you. That is all we have for today. And thank you very much Drs. Braun, Bowles, and Hutchison for a delightful conversation. Thank you so much to all the listeners tuning into this episode of the ASCO Education Podcast. [MUSIC PLAYING]   SPEAKER: Thank you for listening to this week's episode to make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit elearning.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional 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. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

This episode features Dr. Quyen Chu, Chief of the Division of Surgical Oncology at Louisiana State University. A prominent surgeon, humanitarian and writer, Dr. Chu shares his life stories, from fleeing Vietnam as a young child, to finding his calling, and giving back through work in impoverished U.S. communities and war-torn regions, including Iraq, Kurdistan and Vietnam. Subscribe: Apple Podcasts, Google Podcasts | Additional resources: education.asco.org | Contact Us Air Date: 01/04/22   TRANSCRIPT [MUSIC PLAYING]   SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional 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. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] PAT LOEHRER: Hi. I'm Pat Loehrer and director of the Center for Global Oncology and Health Equity, Indiana University. And welcome to another episode of Oncology Etc. DAVE JOHNSON: And hello. I'm Dave Johnson at University of Texas Southwestern in Dallas. Pat, great to have another session today. PAT LOEHRER: It's good to see you again, Dave. I'm really excited about our guest today. And I think both of you and I were talking about this book that came to mind when we thought about having Quyen here. But it's a book by Abraham Verghese entitled My Own Country. And we hope to have Abraham on in another session of ours. You know, Abraham's story of growing up in Africa, and moving to the United States, and moving to the South in Tennessee in a time of HIV was really an extraordinary journey for him. DAVE JOHNSON: Yeah, an amazing story, settling in East Tennessee in the Appalachian Mountains, and then going to the Northeast to do additional training, and then returning to that part of the country during the height of the AIDS epidemic-- really a remarkable story. For those who have not read it, we both recommend it very highly. Today's guests we're incredibly excited about both. Dave and I met Quyen Chu in the Leadership Development program for ASCO. He was in the first class. He's currently the professor of Surgery and chief of the Division of Surgical Oncology and holds the Edward and Frieda Green Professorship in Surgical Oncology at LSU in Shreveport. He earned his MB degree at Brown Medical School in Providence, trained in general surgery in Massachusetts at Springfield and at St. Elizabeth's Medical Center, and then did his fellowship training at Brown University under the mentorship of Dr. Hal Wanebo, who was a wonderful surgeon and very active in ECOG in the Southeast group. Dave and I knew him. He's authored-- or co-authored more than 178 publications, a number of book chapters, a couple of books, including translating one of the surgical textbooks into Vietnamese. He has been an extraordinary human being. And one of the things we want to explore is his journey from childhood until now. In 2013, he was appointed by President Barack Obama to the board of Vietnam Education Foundation. He has worked in impoverished areas in Louisiana but also in the war-ravaged parts of the world, including Iraq, Kurdistan, Vietnam. He is truly a special breed of humanists who-- I think he looks back at his roots. he sees the bright possibilities of the future and reflects on what he can do to make a difference. It's just a great pleasure to have you, Quyen, to join us today. QUYEN CHU: Thank you very much, Pat, for that great introduction. It is very heartwarming, and I look forward to this podcast. DAVE JOHNSON: So Quyen, why don't we start a little bit-- I mean, Pat's mentioned your background. Tell us a little about how you got here and about your family and their journey from Vietnam to the United States. QUYEN CHU: Sure. I immigrated to the United States in 1975 right after the fall of Saigon at the end of the Vietnam War. My father was a South Vietnamese officer in the army, which means that he fought alongside with the Americans so that when the Americans pulled out, South Vietnam fell. And so because he was an officer, we were-- basically had no choice but to leave the country. Otherwise, he would be in a re-education camp, which might mean that we would never see him again. So we left Vietnam in '75. I was seven. We left on a ship, and then we also left-- then we transitioned to boats, and then we went to the Philippines for several months. And then we finally got sponsored by a church in Florida. So then we stayed at Eglin Air Force Base for several months before we actually went to our home in Florida. I grew up there and basically was-- grew up in a very impoverished area. It was-- basically it's a rat-infested home that we lived in. My father was an officer. He was a captain. But coming over to the United States, you have to learn English. You have to try to get a better education. And he finally realized that he had to support a family of six, and he took on being a barber. So he was a barber for most of his-- the rest of his career, really, raising a family of six. And I was there just to do the very best that we could. Throughout it at all, we knew that we were in the right place. And we knew that America doesn't give everything out for free, but we also know that it's a great, great land of opportunity. The philosophy is that if you apply yourself, do the very best, follow the rules and regulations or laws, you know, abide by their laws, that you can do great things. And that is a great opportunity. So that was embedded in me and my sisters, and those philosophies have stood the test of time thus far. PAT LOEHRER: You know, I read a little piece when-- you told a story about arriving here in Florida and a police car pulling up to your house. Can you relate that story? QUYEN CHU: It's the memory that I will never forget. And in fact, I remember it every Thanksgiving. So it was around Thanksgiving. We really didn't know what it was. We just moved into a new house. And it's funny because when we drove by the new house, we saw the garage. And we felt, oh, my god, we're going to live in that garage. This is great. This garage is going to be our house. This is great. There's so much space. And I remember when we asked the driver, the driver goes no, no, no, no, that's where you park your car. The whole house is yours. And we were just amazed. But anyway, so around Thanksgiving, we saw-- a police car drove up to our parkway. And I saw, and I was scared. And then I called out my dad. And I said, Dad, there's a police car here. What did we do wrong? And he was so scared. And he said, Son, you know, I will take care of this. So the police came and knocked on the door. And when my dad opened the door, he claps his hand, and he just bow, just like this, several times to the policemen and say, we're-- in broken English, we're sorry. We know English. We did not mean to break any laws. Forgive us. And the police just smiled. And he says, no, no, no, no. We're here to greet you as a new neighbor. And it's Thanksgiving, and we want to give you a turkey. Then he waved to the other police to come over, and then the other police came out with a big old turkey. And they hand it to us, and they said, welcome to the neighborhood. And we were so happy. My mom-- just about to cry. And we felt that, hey, this is now our new home, and we felt that this is not going to be a strange land, that we're going to create a life for ourselves here. DAVE JOHNSON: It's a remarkable story, Quyen. That type of story just makes it even more special. You mentioned that you had several siblings. Where do you fall in the hierarchy? And what are your siblings doing? QUYEN CHU: So I'm a second-oldest. So my oldest sister-- she went to Cornell, and she is now a full professor of biochemistry at Union College. My younger sister, who's a year younger than me-- she graduated from Dartmouth, and she is now working at industry and also, in the medical field. She holds a PhD from Columbia. And then my youngest sister graduated from Oberlin College, and she is now working in the hotel business. So we're very blessed. We feel very excited about the opportunities. And we look back at our lives every Christmas when we get together as a family, and we reflect back at the lives that we've gotten. And we also feel bad about family members who couldn't make it over here and wonder what their lives would have been like had they come over here. And then we also wonder what life for us would have been like had we not come over here. And through it all, we felt that we really, really hit the jackpot in life and that all of us were very, very lucky to have this life that we have. PAT LOEHRER: I can't imagine the pride that your parents have of all of you and how much pride you have for him. I mean, it's extraordinary. Can you just because I've never-- none of us have been through this, what you've been through. But what was it like being seven years old in the middle of this war in Vietnam? What memories do you have of that? QUYEN CHU: Yeah. I remember when I was playing with my cousins. And of course, in Vietnam, we live under a house full of cousins, aunts, and the extended family. I remember leaving them, and I felt very lonely in America. Of course, each family has its own separate family. And I just felt like it was not-- it was very lonely. But we did have very nice neighbors. We did have great people that really was very supportive. Of course, as a young seven-year-old, the neighbor's daughter was around my age. She was cute, so, of course, I'd find every reason to visit them and say hi to them. But other than that, it was a very nice place to grow up. They have their challenges, obviously. What I remember as a second grader-- I saw all the boys. To me, I thought they were all brothers because they were all Caucasian. They all have blond hair. I couldn't tell the difference who's who, but I thought they were all related. But they were very nice, of course. There were curiosity between us. I've never seen African-Americans until I came over here. And I befriended a Hispanic guy, as well as an African-American, as well as my best friend. To this day his name I still remember. It's Jeff. He was very friendly. Of course, I experienced some racism, but I think that's expected because I look very different. There were a lot of mixed messages coming out of the Vietnam War. But I think that through it all, the challenges, I realized, that there are more good people than there are bad people and that people who were bad-- probably because they were insecure, or they just didn't know me. And then there were those who did finally get to know me. They turned out to be great people. I've learned throughout my 53 years on this earth that people have so many things in common that when we do have conflict, it's probably stemmed from insecurities rather than pure hatred. DAVE JOHNSON: Yeah. You went to undergraduate at Dartmouth. Is that right? QUYEN CHU: Yes. sir. DAVE JOHNSON: So I seem to recall-- maybe you told us this in the LDP program, but you had an interesting experience when you showed up on campus at Dartmouth. QUYEN CHU: Yeah. DAVE JOHNSON: Can you relate a little bit of that to us, as well? QUYEN CHU: Sure. So, again, coming from a family where your dad is a barber, I had limited means. So I basically had, I think, one tote bag that I packed together. I took a Greyhound two day's trip to Dartmouth. And I got there on the campus. It was a beautiful green campus. And I was a little bit hesitant, a little bit reserved because there were a lot of Caucasians and whatnot. And I was a little bit, you know, introvert somewhat. And when I got there, I saw a Frisbee flew by me. And I grab it, and then the guy goes, hey, you want to come and play with us? And I'm like, well, sure. And next thing you know, we hit it off like a bunch of 18-year-old kids-- no worries in our mind, just glad to be on campus. And we hit it off. And I realized that, hey, you know, my reservations were basically based on my own biases rather than the reality. And then I've realized that the reality is that a lot of the kids there are just like me-- just want to find friends, just want to hang out, just want to have a good education. And they weren't being judgmental about anything, and that made me really-- it felt really good. DAVE JOHNSON: Frisbee diplomacy, I guess, is we should call it. Maybe we should throw a Frisbee to Putin. I don't know. QUYEN CHU: That's right. PAT LOEHRER: Tell us a little bit about your journey to become a surgeon. QUYEN CHU: OK. So my dad and mom instilled with me the importance of education. They told me, now listen, you have a choice-- either be in the same rut as us now, or get a good education and get out of this rut. So I really didn't have any choice but to study hard. And I studied hard, and I got an opportunity to go to Dartmouth. I felt very, very lucky with that. They gave me a full scholarship. They believed in me. They saw something in me that I was very happy that they saw. And then I applied to medical school at my sophomore year at Dartmouth, and I got in. I was very excited about that. And I started off wanting to be a pediatrician, but then I realized that what I had to turn in my sheet of the patients that I saw, everything had to do with procedures and techniques. I wrote down there I did a spinal tap, I did a chest tube, I helped intubate, I did all of that. And it was really my pediatric mentor who says, it sounds like you should be a surgeon, not a pediatrician. And that kind of got me thinking about it. And then I rotated a service with Dr. Wanebo and really fell in love with surgery. It was tough. It was rough. But I felt that this is my calling. I felt very fortunate looking back at only the number-- maybe they admitted 100 students. And I felt very fortunate that I was among those. And I knew that it was an opportunity that I did not want to waste, that I did not want to take for granted. I wanted to do everything I can to make sure that I learn as much as I can and hoping that in the future, I would give back to the country, the community that gave me a life. DAVE JOHNSON: Yeah, my mentors suggested that I should be a forest ranger as opposed to a physician. [LAUGHS] PAT LOEHRER: Yeah I think I shared before I got, on one of my medical-school applications, they not only rejected me, but they said, good luck in whatever career you decide to go into. [LAUGHTER] I was going to be a pediatrician, too, but I envisioned all these kids just laughing and having a great time. But they were all crying, and the parents didn't like me either. And so I decided to find a different life. You have had this extraordinary journey of giving back, as I mentioned at the onset, and not only going back to Vietnam but also, going to Iraq and going to many other countries here. And about five years ago, you received the ASCO Humanitarian Award, which was so deserving for you. DAVE JOHNSON: Very deserving. PAT LOEHRER: But tell us a little bit about these efforts. What has pulled you or driven you to do so much of your humanitarian efforts around the world? QUYEN CHU: Well, first of all, I want to credit my wife Trina, who's been there for me. She's basically the backbone of my life, allowing me the opportunity to pursue my passion. She's a lawyer. She put her career in the back seat so that I can have a successful career. So I want to make sure that I acknowledge her sacrifice and her love. Because of her love and her understanding, I was able to pursue my passion, which is giving back. My colleague, Dr. Gazi Zibari is from Kurdistan. And one day, he showed me pictures of the Kurds, and he gave me the history of the struggle the Kurds. And it was reminiscent of the struggles of the Vietnamese, so it resonates with me. And I said to him one day, hey, listen, when you do go, I would love to join you. And so I did. And from that point on, I returned, I think, four or five additional times. We did not return last year or so because of COVID, but we're planning to return again to Kurdistan and Iraq. But it was an opportunity for me to really give back what I wanted to do all along, which is to render care to the less-fortunate individuals of our lives. I also went to Vietnam, Nicaragua, Honduras, and also on those different mission trips. And, you know, Dr. Zibari and I have gone together for many of these trips. And we come to realize, you know, what-- the great thing to do is capacity building. In other words, we should visit these countries not just once but several times to make sure that the surgeons there feel comfortable with the procedures that we taught them and that, hopefully, that they will also teach the other surgeons the procedures, the techniques that we taught them. And we were very pleased when we went back to see that these surgeons were very adept in what they were doing-- Whipples, liver resection. They were doing phenomenal things. In fact, I think the greatest sense of pride in me was to see a young surgeon in Kurdistan who did a laparoscopic right-liver resection bloodless. We felt very proud because-- I was looking at Dr. Zibari, and I said, you know what-- I can't even do that. And it's amazing to see how they have not only learned our skills, but they exceeded us. And isn't that what we all want, that our mentees to be better than us? And so to me, that was a great sense of pride. At the end, the young man came up to me and says, mentor, I hope I did it right. Did I make any mistake? And I chuckled. And I said, no. I could not have done what you've done. You have done amazingly. And he was so happy. He was so proud. He says, I'm so glad that I make you proud of me, Dr. Chu. So to me, that's probably the greatest thing is to see your mentee better than you and still see that respect that you got from them. DAVE JOHNSON: We're really happy you mentioned that because one of the themes of our podcast has been mentor and mentor relationships. And you had a remarkable relationship with Dr. Wanebo. Would you like to expand on that somewhat or tell us about that relationship? QUYEN CHU: Sure. Dr. Wanebo-- I always joke around. I said, Dr. Wanebo, you're a gifted surgeon with an internal-medicine demeanor. He is just so nice. He never loses his cool. And the great thing about him is that every time I have an idea, he would always push me to pursue it. There's never been a, no, it can't be done. No, that's not how-- you will never get it done-- never like that. It's always, this is a great idea, Quyen. Why don't you pursue it. And in fact, he would give me deadlines and say, why don't you get back to me in two weeks and see where we go with that. I remember visiting him in his very busy clinic. And his PA would always trying to brush me aside because they were so busy. And he would always say, no, no, no, come on, Quyen. What do you have for me? What do you need? He would always make time, even in this busy clinic, to help mentor me. And then whenever I'd write a paper or abstracts, he would look at it. He would fix it, and he would send it back to me and ask me to work on it. So he's been a great mentor, just a great person all around. PAT LOEHRER: Quyen, if you could think about a young professional or young student right now and give them some advice, what would it be? QUYEN CHU: I think the best advice is that you pursue your passion. I know it sounds so trite, but pursue your passion. Seek out mentors who believe in you, and avoid those naysayers because I think that young people have so many insecurities. And they're great people. They're so naive, and they're so fresh. They're not tainted with all of the flaws of the world. And I always worry that when they encounter negative people, it fills their mind with negativity. And that, to me, is not very constructive. So I would advise young people to seek out optimistic, idealistic people to be mentors. And then I think the rest will follow. And they will learn what can be done, what can't be done. Obviously, you need a mentor to advise them so that they don't fall into your trappings of making major mistakes. But I think that mentors should be someone who is inspiring, who is positive, who can tell them that, hey, you can do it. And if you fail somewhat, it's not the end of the world. Seek out your passion, and never give up. DAVE JOHNSON: That's great advice, Quyen. I have just one more question I wanted to ask and perhaps should have asked a bit earlier. How did you end up in Louisiana? QUYEN CHU: That's a great question. So at the end of my fellowship, I had opportunities to stay up north. Then I got a call from my previous partner to say, hey, listen, I'm in Shreveport. Why don't you come by. In fact, it's funny because when I heard the word "Shreveport," it sounds, to me, Chinese. And I said, why would I want to go to China to practice? I didn't know where it was. And then they said, no, no, this is in Louisiana. And I really thought about, nah, I don't want to go. But my wife said, listen, why don't you just go down there and take a look so that at least you won't offend the person who asked you to come down. So I went down there for an interview. And it really resonates with me about the needs, that patients there did not have, in my opinion, good surgical oncology care. There was a huge need. I saw the mortality for esophagus, gastric cancer. They were high. I saw a lot of cancers that were neglected. And the chair there, Dr. Turnage, was wonderful. And he said, listen, Quyen. Nobody's going to compete against you. We just got a huge need. I think that you would find a niche here, that you can really, really develop a practice here, and then I can mentor you for the academic part. So I thought about it. And then I talked to Trina, my wife. And I said, this is what I wanted to do. I wanted to give back. I didn't want to be just another spoke on the wheel. I wanted to make a difference. I think I can do this here. And so we took a chance, and I think that we're very happy with that decision we made. PAT LOEHRER: Well, Quyen, I just, as I reflect on this and think about that leadership-development program, there are many different kinds of leaders, but I can't think of a person who serves as a better example as a servant leader than you. You have given of yourself in so many ways. In this particular past few years. Where there's been so much angst and polarization in this country, and even consideration of isolationism and not having immigrants come into the country, I hope people listen to this, the podcast, and realize what the impact was of a man and a woman who decided to bring their kids over here. And he became a barber, which is not that prestigious of a job, if you will. But his impact on this country is huge. Mark Twain had a little quote. He said, "The two most important days of your life are the day that you were born and the day you find out why." And when you guys were born in Vietnam, you had no clue what was going on, but you are one of the fortunate people who know why you're here, and that's to make a difference. And I just want to tell you that you have. Thank you so much for your time with us today. DAVE JOHNSON: Yeah, it's been great. QUYEN CHU: Thank you very much. DAVE JOHNSON: Quyen, this has been marvelous, and we're both great admirers of yours. And I could not agree more with Pat about the impact that you've had. One thing we like to do with our guest at the end is ask you if there's something you've read recently, or a documentary, or something, a movie or something you've seen that you would recommend to us and to our listeners. Is there something special that you've read recently or maybe seen that you'd like to recommend? QUYEN CHU: Yes. So there's a book by Mr. David Epstein called Range. It's a phenomenal book. It's a book that contrasts Malcolm Gladwell's philosophy about 10,000 hours to be an expert. Mr Epstein took a different approach. He took the approach that you have to be a generalist. In other words, you have to do many things in life before you can hone in on one particular skill set to become an expert in that. So to me, that book, Range, is a fascinating book. I'm midway through. And it's just-- it's a beautifully written book, and it just gives a different perspective of life. I've always loved books that give a different perspective for a particular topic. And I would highly recommend our readership to read Range by David Epstein. DAVE JOHNSON: Yeah. I also read that, and it is a fabulous book. I couldn't agree more. QUYEN CHU: Yeah. DAVE JOHNSON: Well, we've come to the end of our session. And I really want to take this opportunity to thank our listeners and thank Quyen for joining us. It's been a marvelous session. QUYEN CHU: I appreciate it. Thank you, David, and thank you, Pat. DAVE JOHNSON: Thanks for tuning in. This is an ASCO educational podcast, where we will talk about anything and everything, really. We really will. So if our listeners have any ideas for our topic or guests that you'd like to hear, please email us at education@asco.org. Thanks, again, and remember that November 9 is National Louisianan Day. And Pat, just so you know, November 16 is National Indiana Day. I'm sure you already knew that. PAT LOEHRER: I love it. Every day's Indiana Day. DAVE JOHNSON: No, every day is Texas Day. PAT LOEHRER: Thanks, guys. [MUSIC PLAYING] SPEAKER: Thank you for listening to this week's episode. 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.

Adjuvant immunotherapy is a game-changer for early lung cancer, but it is not the best choice for every patient. Hosted by Dr. Rami Manochakian (Mayo Clinic), Drs. Karen Kelly (University of California Davis) and Howard West (City of Hope Cancer Center) explore considerations in shared decision making and personalizing therapy through patient cases.  Subscribe: Apple Podcasts, Google Podcasts | Additional resources: education.asco.org | Contact Us Air Date: 12/15/21   TRANSCRIPT [MUSIC PLAYING]   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. RAMI MANOCHAKIAN: Hello, and welcome to ASCO Education Podcast on new therapies for lung cancer. My name is Dr. Rami Manochakian. I'm a thoracic medical oncologist at Mayo Clinic Florida. Today, I have the pleasure to speak with two very well known, nationally and internationally, thoracic medical oncologists specializing in the fields of lung cancer. I have Dr. Karen Kelly, who is a professor of medicine and associate director for clinical research at the University of California Davis Comprehensive Cancer Center. And I am also joined by Dr. Jack West, who's a medical oncologist as well as associate clinical professor in medical oncology at the City of Hope Comprehensive Cancer Center. In October of this year, the FDA approved atezolizumab for adjuvant treatment of stage II to IIIA non-small cell lung cancer following a resection and platinum-based chemotherapy. This is the first adjuvant immunotherapy approved for lung cancer and has the potential to improve cure rates. In this podcast episode, we'll discuss how to implement this new therapy in the care of real-world patients. We're going to start the conversation today with a patient case. We have a 64-year-old woman who is a 15-pack-year smoking history, quit several years ago in the 1980s, and was found on a screening CT to have lung adenocarcinoma. She underwent a full workup that included a negative EBUS and ultimately underwent a surgical resection with right upper lobectomy. Surgical pathology showed a 3.2-centimeter invasive adenocarcinoma with some additional lepidic noninvasive AIS, and two out of eight N1 nodes were positive. The final staging was a pT2aN1 stage IIB disease. She had a molecular testing that included NGS that showed an EGFR activating mutation in exon-- 21-L858R substitution with no other driver mutation. And PD-L1 was checked, and it was 2%. And we'll start with the first questions. And I'll start with Dr. Kelly, and then we'll ask Dr. West also to give his opinion. Given the currently available treatment and the new approvals, all the research evidence and guidelines that we have as of now, 2021, how would you manage this patient? KAREN KELLY: Well, I think that that is a great question. And of course, for this patient, who does have that EGFR L858R mutation, that is a very important finding to have. And I applaud the ability to get the NGS sequencing, because that is important here, for patients today, based upon ADAURA results, which was the randomized trial after resection for patients with early-stage disease who got chemo or not, randomized to osimertinib versus placebo. And so I think for this patient with that EGFR mutation, my driver in my treatment plan after adjuvant chemotherapy-- and I do want to make that important distinction here that, even though ADAURA did allow patients to not have chemotherapy, we are strong believers in evidence-based medicine that has shown that adjuvant chemotherapy has improved survivals and cure rates in this patient population. So after, I would begin with giving adjuvant chemotherapy for four cycles, cisplatinum-based. And then, based upon ADAURA, offer this patient osimertinib. I do not believe that this is a patient that would benefit from a immunotherapy regimen. And I'm going to let Dr. West talk about that component of this case-- that immunotherapy, I believe, would be contraindicated. RAMI MANOCHAKIAN: Excellent. Dr. West? JACK WEST: I would say that some in the audience may know that I've had some issues with the design of ADAURA and had been critical of it at the time of its release. And I think it is always a little challenging when we have disease-free survival results, but not overall survival in a curative setting, because I believe our goal here should be to improve survival. And it's not clear, particularly with a treatment that is still ongoing, whether this is really just forestalling progression and going to translate to a survival benefit. So that comes up with ADAURA. But that said, we are now in a situation where we have a remarkable improvement in disease-free survival with ADAURA that gave the adjuvant osimertinib for patients with a tumor harboring an EGFR mutation. And we don't yet have mature data for overall survival. I think we need to work with what we have, and that is giving the patient the benefit of the doubt and presume, until we see otherwise, that the remarkable improvement in disease-free survival will, we hope, translate to an improvement in overall survival. So certainly, for patients with node-positive disease, I would definitely favor at least offering, if not clearly recommending, osimertinib. I would talk about the caveats that we don't yet have overall survival, but I would say that, based on what we know, with the limitations, I would be encouraged and would favor that. And the important challenge, I would say, is what to do when you have potentially competing options, like adjuvant immunotherapy, specifically-- now in FDA approval for adjuvant-- atezolizumab, based on IMpower010 results that we first saw at ASCO in 2021 and have learned more about. And the results are also very impressive for at least a subset of patients, specifically those with stage II to IIIA disease and who have PD-L1-positive disease. I would note that, when looking at subset analysis of IMpower010, the benefit is much more impressive in the subset of patients whose tumor has PD-L1 expression in the high range, 50% or higher, where the hazard ratio for disease-free survival is 0.43. And in contrast, for the patients with low PD-L1, that hazard ratio for DFS is 0.87. And of course, we don't yet have overall survival for this trial either. So I would say that there is, arguably, a question of what you would do if someone has PD-L1-positive disease and an EGFR mutation. But I would note that we have seen in advanced disease that patients with a driver mutation-- say, particularly, EGFR-- are overwhelmingly more likely to benefit from targeted therapy against EGFR than immunotherapy. And if anything, it seems that PD-L1 expression for patients with an EGFR mutation or an ALK rearrangement doesn't necessarily mean the same thing as it would for someone with wild-type disease. It just is not nearly as strongly predictive of benefit, and the benefit with targeted therapy is far greater. RAMI MANOCHAKIAN: Thank you to both of you. Really, I think you brought both a great point. I like what Dr. West said about we need to give the benefit of the doubt. We need to deal with what we have, because right now we don't have the OS benefit, talking about, obviously, the ADAURA, or even the IMpower. And discuss with patients. Discuss what we're doing. Include them in the treatment decision and plan, and tell them this is why we're considering this and not. It appears that everyone feels that this patient, obviously, would not be the best candidate for adjuvant atezolizumab. Rather, very possibly get an adjuvant targeted-therapy osimertinib. Speaking about adjuvant atezolizumab, I want to ask, who else you would not recommend, maybe, adjuvant atezolizumab to? And I'll start with Dr. Kelly again. KAREN KELLY: So I think that we have learned a lot about other driver mutations based upon what we know about EGFR. And EGFR really has been the prototype for all the other mutations. And pretty much, they align with the findings with EGFR, particularly those of ALK, ROS1, and then we get into RET. And we can also talk about HER2. And I think the difference here, between that category and that group of oncogenic drivers, is that they're characterized by being in patients who are never smokers. And so in my opinion, this group of patients that have those additional mutations-- either ALK, RET, ROS1. I would say, also, HER2-- those never-smoking, oncogenic-driven aberrations, really, would probably fall, in my opinion, into the same category that I don't think that they would be the best for atezolizumab. I also base that on retrospective data from the IMMUNOTARGET data that came out in advanced disease, with monotherapy looking at a retrospective large series, multi-institutional, that showed that there really wasn't a benefit for mono-immunotherapy. Now, I will say that, of course, we do have oncogenes that are smoking-related-- that being KRAS G12C, now, remembering that not all KRAS are smoking-related. But something like KRAS G12C. BRAF, typically, as well. Half of the MET oncogenes are in patients who are smokers. So I think if you're a smoker and you have an oncogene, then I think that it would be reasonable. Again, based upon retrospective data-- I would say even based upon my own data from California-- we have found similar results. Even when you give immunotherapy with chemotherapy in patients with oncogenic drivers, they just don't have a benefit from immunotherapy. And I think we can logically make sense of that. They are more simplistic tumors. They don't have high tumor mutational burden. They don't have high PD-L1, for the most part. They're typically more characterized as being cold. So I think it does make sense that this group of oncogenic-driven cancers, particularly those in never-smokers are really more cold tumors and don't respond. So I would add these others to the list that we do have data on, and that, of course, is EGFR. RAMI MANOCHAKIAN: Dr. West, your thought? Especially, it looks like we're heading one way or the other to say that every patient with early-stage needs NGS testing. JACK WEST: I think that we are in a challenging place where the principles are ahead of the actual data that we have. I think that we have been struggling with this for a few years now with things like the PACIFIC trial, where we've had very impressive data for not just disease-free survival, but now overall survival. But that was a pretty broad, inclusive population. It included patients with an EGFR mutation, ALK rearrangement, and didn't really specify otherwise. And so the question is, do we broadly interpret that, well, if they were eligible for the trial and the trial is positive, they should be treated this way? Or do we make, I think, very logical inferences from stage IV disease that not only do these patients often not seem to benefit at all from immunotherapy, but that we could put ourselves in the challenging situation of giving immunotherapy and then having their cancer progress, and needing to give them a targeted therapy where there could be a harmful interaction between the osimertinib that we want to start and the immunotherapy that is still in their bloodstream? And so that's a real challenge. So I think that we need to, now, do some extrapolation. And because of that, it does make sense to want to have this information to individualize the recommendations for the patient. And it's not a big leap, based on what we know about ALK, to presume that these patients are not going to be big beneficiaries or, likely, beneficiaries at all from immunotherapy. I agree with Dr. Kelly about ROS1 and some of the other never-smoking-related driver mutations. I think it is important to say that we shouldn't paint all driver mutations with the same brush. We have seen from IMMUNOTARGET that KRAS and BRAF are not in the same category, and so we need to think of these individually. But I do believe that this information is going to be really helpful to make an informed, thoughtful decision for the individual patient in the exam room with us about whether they personally are likely to be beneficiaries of immunotherapy, targeted therapy, or whether they should withhold all of those. KAREN KELLY: Can I make one additional statement? I just want to add to what Dr. West said, particularly raising awareness about the harm factor. I think, as physicians, we're very focused on wanting to help the patients in terms of, when we look at these biomarkers, let's look at them and give you what works for them. But we have to remember now, with the oncogenic drivers, that we can potentially harm them if we give them immunotherapy. So I think we have to remember, now, the harm factor really comes to the forefront when we talk about immunotherapy and oncogenic drivers and the critical importance of knowing. Yes, we want to know if we can give osimertinib to those patients who are EGFR-positive. But in the same breath, we want to say, oh, immunotherapy would be harmful. So I think that's a little bit of a switch that we have to, as physicians, remember to have that really important conversation about why we don't want to give them immunotherapy. I will say, many of my patients with EGFR or ALK or ROS-- they come in, and they want immunotherapy. And you really have to spend time explaining to them why they are not the best candidates for immunotherapy. RAMI MANOCHAKIAN: Great point, great point. And just one very quick question before I move two Case 2. Are you both testing for NGS for every early-stage cancer patient that comes to your clinic? JACK WEST: I'll say that I would be most inclined to do that for a patient where it's likely to have an impact in the more immediate future. I would not say that I feel that this is a mandate for someone with a less-than-2-centimeter nodule, node-negative disease. You can argue that it would be nice to have this information at the time of relapse. But I think that, in general, you'd want to biopsy to confirm progression, relapse, disease, and the most important biology is what it is at the time of relapse and not what was resected two years earlier. So to me, if it is potentially going to have ramifications for immediate management, so certainly for a node-positive cancer, I would say so. I think it's debatable about whether to do this in someone who has a significant smoking history and a squamous cancer, because the pre-test probability is not high. So I don't want to be too heavy-handed about that, but I would say it makes a lot of sense to think and act beyond the narrow indications that we have now just for looking at EGFR as well as PD-L1. KAREN KELLY: Yes, I think to the point of harm. I think that we do need to be doing NGS testing in these patients that, I would say, meet the eligibility criteria from the 010 trial, in terms of adenocarcinoma. I do agree with Jack that a small 2-centimeter tumor-- I wouldn't be checking that. But if you meet the eligibility requirements, and you're thinking along those lines for that patient, then I definitely would do the NGS, not only-- as I said, because you don't really want to harm a patient. If you don't know that they have RET or ROS, you could potentially harm them if you gave them immunotherapy. So I think that is my point. We've got to remember. Now we have to think about helping our patients, but also not harming the patients. RAMI MANOCHAKIAN: Excellent. Thank you. I'm going to move on to Case 2 briefly. This is more of a case of a patient that is a good representative of a patient who meet the eligibility for the IMpower trial that led to the approval of atezo. 71-year-old male who presented with chest pain. Workup showed a mass, a 4-centimeter left-lower-lung mass. A full workup, including PET and EBUS showed that lymph nodes were negative. Also underwent left-lower lobectomy, and his staging was stage IIB, T2b, N1, with two hilar lymph node were positive. So again, very similar to the first case. A little just different size. NGS testing here did not reveal an actionable mutation, and PD-L1 was high, at a 60%. So simple question, Dr. Kelly. Is this patient a candidate for adjuvant atezo? What benefit would you expect to see? I know we touched base on it a little bit in the first case. And then, how would you talk to your patient about potential side effects? KAREN KELLY: So I think that this is the ideal patient for adjuvant atezolizumab, based, of course, on that very high PD-L1 of greater than 50%. That's where the data and the driver of the positive results really came from with that hazard ratio of 0.43. Remember that, in the subset analysis of the 1 to 49, the hazard ratio was 0.8 or higher. So it was really driven by the high PD-L1 status. So I think that this is a perfect patient to receive the adjuvant atezolizumab. When I talk to patients about side effects, I begin always with saying that we now have enormous data points about the side effects of all of the immunotherapy drugs, based upon stage III disease and stage IV disease and other diseases. And these agents are, overall, well tolerated, but they do have some risk of serious side effects that are related to inflammatory signs and symptoms. And so I do think that it's important to have a discussion about what I just group as "itises" that patients can really have. Any "itis" can occur. But the seriousness is, really, anywhere between 3% and 10% of that. And the other thing that I'm very vigilant about with the patients is that-- I remind them that these side effects can occur at any point in time while you are on the drug, and then through several months after you've stopped the drug. So I think that that's really important to be very vigilant. It's a very different approach than chemotherapy, where we really have a great understanding of exactly when those nadirs are. So I spend time making sure-- and every time I see the patient, going over that whole list again to make sure-- that they are doing well. So that's really how I approach a patient. And of course, make sure that they have a good understanding of those side effects. RAMI MANOCHAKIAN: Thank you, Dr. Kelly. Dr. West, do you agree that this patient is the ideal candidate for atezolizumab and you would offer that? JACK WEST: I would. And I would say that it's a slightly different situation from why ADAURA is compelling to me. And I would say that ADAURA is most compelling despite the limitations in DFS being assessed in the middle of ongoing EGFR-inhibitor therapy. Here, we don't have a hazard ratio of 0.12 or 0.17 or something like we did in ADAURA. But it is certainly impressive, certainly for the high-PD-L1 subgroup. And this is in patients who have completed their therapy in the past, and the benefit is sustained. We also know from the mechanism of action over years of treating patients with advanced disease with targeted therapies and immunotherapy that immunotherapy can have remarkably sustained benefit, even after patients stop it. And so it's not hard to envision that patients will have a time-limited course of immunotherapy and still have very sustained, potentially permanent benefit from it. So I am impressed by the improvement in disease-free survival, even if it isn't of the same magnitude as what we saw with ADAURA, because it is being measured after patients have completed that therapy, and in particular for the patients with high PD-L1. I do think that we need to be very thoughtful about whether patients in the 1% to 49% group are likely to benefit, in terms of overall survival, because we don't yet have overall survival data. The hazard ratio for disease-free survival is 0.87 here. And we've talked about the risks with immunotherapy are not generally catastrophic, but a lot of patients will have somewhat modest but sustained issues with thyroid problems, et cetera. And this is the adjuvant setting. Patients may already be cured, and you're talking about an additional year of coming into the clinic for therapy. That is very costly and can have toxicities that I wouldn't want to minimize. So for me, personally, I would say it is quite compelling for those with high PD-L1. It's something to discuss for somebody with low PD-L1 in the 1% to 49% range, but not something that I would consider nearly as striking a benefit. It does seem to me, from the subset analysis, that much more of the benefit of immunotherapy is limited to those with high PD-L1. RAMI MANOCHAKIAN: Thank you. So in conclusion, if I ask each one of you, please, to give a word of advice for oncology providers regarding the implementation of adjuvant atezolizumab into routine care today-- and also, of course, we know this field is evolving in a very great and promising way. What are you envisioning in the near future will bring for patients with early-stage lung cancer and, of course, could change what we're talking about today? Dr. Kelly? KAREN KELLY: So first of all, I think adjuvant atezolizumab is a significant advance in the field of adjuvant therapy for lung cancer. Remember, we have not had an advance in many, many, many years. And in the subset of patients, particularly those with high PD-L1, I think the data is impressive. To Dr. West's point about the 1 to 49, I do agree that we have to be careful, but we need more data. And I think that is where having the results of the other trials will be very, very helpful. Now, we all know that PD-L1 is really a gradient. And so I do want to say that we can't just focus on one parameter from these trials. We do that, particularly, I think-- the PD-L1s greater than 50% with a hazard ratio of 0.43, a solid number there-- that works. But when you're at 45 or 40 or 30, you really need to take into consideration other patient characteristics and other factors in making those decisions. And of course, that's a shared decision with the patient as well. So I think it's important to remember there are other factors that we all synthesize when we're talking to a patient and trying to make the best recommendation. So that's the art of medicine, is taking the science and putting it together to really help that patient that is sitting in front of you. So nonetheless, this is an advance. And remember, this is how we started with stage IV disease. So I really do think, to Dr. West's point about the fact that these patients, after a year, are having this really impressive disease-free survival, we're very optimistic that that will translate into cures. Now, I want to be clear here that overall survival doesn't mean cure. But again, if we look at cure fraction, I think we will see that with immunotherapy, because we are seeing that. And I know Dr. West and you also probably have cases where you're pretty confident that you've probably cured those patients with stage IV disease. We see that in a very silent way. [LAUGHTER] JACK WEST: I really agree. I have been commenting recently, reflecting that we have been pretty reluctant to say the C word, say "cure" for patients who have phenomenal unprecedented results with immunotherapy for stage IV disease, I think, based on our tenets that it's categorically not curable. But I think that immunotherapy has changed everything, and the rules are different. I would say that the IMpowere010 trial is very important, does change practice, should change practice, and is just the beginning for introducing immunotherapy into the early-stage setting. There are many other trials coming, looking at immunotherapy. In the adjuvant setting, we have seen very provocative data for neoadjuvant, which I think is also quite compelling and has the advantage of giving you more feedback about how your treatment actually worked. You're not treating blind. I think that in the next three to five years, we will have multiple different strategies, options to choose and that it's going to be a real quantum leap in how we translate some of the benefits that we have enjoyed in stage IV disease into earlier-stage disease to translate to better overall survival. I think that we will begin to see that for some of these earlier trials, and so we will be able to talk not just about disease-free survival, but overall survival. We will be talking about this for immunotherapy and targeted therapies. And so just like it's been about 15 years since everything changed in the adjuvant setting with chemotherapy, this is the next iteration of that, where we are working on how best to refine our strategies in a more individualized way than chemo for everybody, but to personalize the optimal perioperative treatment strategy for the patient's individual cancer characteristics. RAMI MANOCHAKIAN: Thank you. Thank you very much to both of you. I don't think we could have ended on a better note. It's definitely a hopeful era for patients with lung cancer. With all the recent advancements and research, I think our patients are living longer, living better. We still have a long way to go and, hopefully, more to happen in this field where we're able to offer our patients some personalized treatment depending on so many different factors. This is all we have for today. I'd like to thank very deeply Drs. Kelly and West for a great conversation and for sharing their insight and expertise. Thank you to all our listeners. Thank you to our wonderful ASCO staff, and hopefully, for more ASCO Education Podcast to keep covering this topic of lung cancer. [MUSIC PLAYING] Thank you all. JACK WEST: Thanks for the opportunity. RAMI MANOCHAKIAN: Thank you. SPEAKER 1: Thank you for listening to this week's episode. 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.