An Unusual Treatment for Chronic Myelomonocytic Leukemia

A 76-year-old female with a past medical history of an extraosseous chondrasrcoma status-post-resection thirty years prior, hypertension, hyperlipidemia, and hypothyroidsimm presented to her primary care physicial with fatigue, two weeks of dyspnea on exertion, lightheadedness, and nausea

Treating Hematologic Malignancies During a Pandemic: Utilizing Telehealth and Digital Technology to Optimize Care.

In late January 2020, Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2) was reported as an outbreak in Wuhan, China. Within 2 months it became a global pandemic. Patients with cancer are at highest risk for both contracting and suffering complications of its resultant disease, Coronavirus 19 (COVID-19). Healthcare systems across the world had to adapt quickly to mitigate this risk, while continuing to provide potentially lifesaving treatment to patients. Bringing care to the home through the use of telehealth, home based chemotherapy, and remote patient monitoring technologies can help minimize risk to the patient and healthcare workers without sacrificing quality of care delivered. These care models provide the right treatment, to the right patient, at the right time

Upfront Treatment of FLT3-Mutated AML: A Look Back at the RATIFY Trial and Beyond.

In April 2017, following the results of the RATIFY trial (1), midostaurin, a multikinase FLT3 inhibitor, became the first FDA approved targeted agent for the treatment of acute myeloid leukemia (AML) (2). The addition of midostaurin to standard induction therapy with anthracycline and cytarabine (7 + 3) rapidly became the new standard of care for treatment-naïve, fit patients with FLT3-mutated (FLTmut+) AML (3). More recently, gilteritinib, a selective FLT3 inhibitor, showed superiority to chemotherapy in the treatment of relapsed or refractory FLTmut+ AML (4). With two FLT3 inhibitors now approved by the FDA—that is, the more selective gilteritinib and the less selective midostaurin—the question of which FLT3 inhibitor to use in combination with chemotherapy in the upfront setting has become the subject of much debate (5–7). Leukemia physicians are faced with the choice of using a more selective agent in the front line vs. reserving that agent for the time of relapse. Here, we evaluate the rationale for both approaches

Caring for AML Patients During the COVID-19 Crisis: An American and Italian Experience.

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the subsequent pandemic have impacted every aspect of oncology care worldwide. Healthcare systems have been forced to rapidly change practices in order to maximize the safety of patients and healthcare providers and preserve scare resources. Patients with acute myeloid leukemia are at increased risk of complications from SARS-CoV-2 not only due to immune compromise related to the malignancy but also due to the acuity of the disease and intensity of treatment. These issues have created unique challenges during this difficult time. In this article, we present the approaches taken by two groups of hematologist/oncologists, one in the United States and one in Italy, who have been caring for acute myeloid leukemia (AML) patients in the face of the pandemic

Efficacy of Half-Day Workshops for Internal Medicine Interns in Educating Breaking-Bad-News Discussions

Background: Adequate end-of-life (EOL) care/breaking-bad-news (BBN) discussions with patients are becoming increasingly essential to adequate patient care. Purpose: Whether a half-day workshop would lead to improved confidence in EOL/BBN care discussions for internal medicine interns. Methods: Internal medicine interns (n = 43) were assigned to participate in a half-day workshop at Thomas Jefferson University Hospital. The workshop involved two standardized patient (SP) interactions involving delivering news of a terminal illness/initiating goals of care discussion with the intervention of SP feedback, a didactic and lecture on proper EOL/BBN discussion. Voluntary anonymous surveys before and after the workshop were utilized to assess impact. Results: A majority of interns felt more comfortable with leading EOL care/BBN discussions after the workshop and had a positive experience. Conclusions: A half-day curriculum is efficacious in educating EOL/BBN communication to internal medicine interns, but should be further assessed in a larger more standardized study involving an objective assessment

The Financial and Psychosocial Impact of Medicinal Cannabis

Introduction: Therapeutic utilization of medicinal cannabis for symptom management in oncology patients is a burgeoning area of research focus. We hypothesize that medicinal cannabis use can result in subjective improvements in quality of life (QOL) metrics for cancer patients. Methods: Adult palliative care patients at a medical oncology clinic are consented to the study after being certified to access medicinal cannabis. After three months, subjective changes in QOL, including well-being, financial burden, pain, chemotherapy induced nausea and vomiting (CINV), and other categories are recorded via telephone interview. Responses are documented with a numerical Likert scale (from 1-5, with a score of 1 = greatly decreased satisfaction, and 5 = greatly increased satisfaction; a score of 3 is no change from baseline). Scores \u3e3.5 were deemed meaningful in terms of improvement. Results: An aggregate of 35 patient scores showed meaningful increases in subjective satisfaction across most metrics. Satisfaction with CINV symptoms showed the most marked improvement, with an average score of 3.63. While pain scores were similar at 3.53, more general QOL metrics were lower, at 3.46. Most patients did not find the cost to be burdensome, with an average score of 3.03. Discussion: The initial 35 interviews of our desired n of 120 suggest that medicinal cannabis may provide analgesic, antiemetic, and anxiolytic benefits for cancer patients. We anticipate that additional interviews will follow this pattern. If so, our study could bolster the evidence that therapeutic use of medicinal cannabis may be helpful for patients undergoing cancer treatment

The Role of Inhibition of Apoptosis in Acute Leukemias and Myelodysplastic Syndrome

Avoidance of apoptosis is a key mechanism that malignancies, including acute leukemias and MDS, utilize in order to proliferate and resist chemotherapy. Recently, venetoclax, an inhibitor of the anti-apoptotic protein BCL-2, has been approved for the treatment of upfront AML in an unfit, elderly population. This paper reviews the pre-clinical and clinical data for apoptosis inhibitors currently in development for the treatment of AML, ALL, and MDS

Pilot Study For Using Fitbit Activity Trackers To Monitor And Predict Onset Of CAR-T Cell Immunotherapy Related Adverse Events Including Cytokine Release Syndrome

Introduction: Immunotherapy using T Cells with engineered chimeric antigen receptors (CAR) is a revolutionary modality for treating cancer, especially B cell malignancies. It also has specific toxicities. The most common toxicities observed are cytokine-release syndrome (CRS) and neurotoxicity. These therapy-related adverse events can range from mild to fatal. If appropriately and timely treated, they have a good prognosis. Thus, further insight into predictive biomarkers can help clinical management of patients and reduce morbidity and mortality. Objective: One of the constitutional symptoms associated with CRS is fatigue. With the advent of activity tracking digital technology, I propose a pilot study exploring the use of fitness trackers to quantify activity level as a potential predictive biomarker of CRS due to CAR T-Cell immunotherapy. Methods: The proposed study would be a single-arm trial. Patients who are receiving CAR-T Cell immunotherapy will be given a Fitbit Flex 2™ tracker. One week of activity data (measured as steps per day) prior to CAR-T Cell infusion will establish patient baseline activity. From the date of infusion, activity levels will continue to be tracked and analyzed through CRS onset. The patient data will be gathered from Fitbit’s server via a customized app built using Fitbit’s Web Application Programming Interface (API). Results: This is a proposed study. No results have been gathered. Discussion: If a correlation is established between activity levels and onset of CRS, it would enhance the current predictive algorithm, allow easier outpatient management and remote monitoring, decrease costs, and reduce morbidity and mortality

A Phase I Trial of Sirolimus with 7&3 Induction Chemotherapy in Patients with Newly Diagnosed Acute Myeloid Leukemia

Chemotherapy remains a primary treatment for younger AML patients, though many relapse. Data from our group have shown that highly phosphorylated S6 in blasts may predict response to sirolimus given with chemotherapy. We report the results of a phase I study of this combination in newly diagnosed AML and the pharmacodynamic analysis of pS6 before and after treatment. Subjects received sirolimus (12 mg on day 1, 4 mg daily, days 2-10), then idarubicin and cytarabine (days 4-10). Response was assessed at hematologic recovery or by day 42 using a modified IWG criteria. Fifty-five patients received sirolimus. Toxicity was similar to published 7 + 3 data, and 53% had high-, 27% intermediate-, and 20% favorable-risk disease. Forty-four percent of the high-risk patients entered into CR/CRp. Seventy-nine percent of the intermediate-risk subjects had a CR/CRp. All favorable-risk patients had a CR by day 42; 9/11 remained alive and in remission with a median follow-up of 660 days. Additionally, 41/55 patients had adequate samples for pharmacodynamic analysis. All patients demonstrated activation of S6 prior to therapy, in contrast to 67% seen in previous studies of relapsed AML. mTORC1 inhibition was observed in 66% of patients without enrichment among patients who achieved remission. We conclude that sirolimus and 7 + 3 is a well-tolerated and safe regimen. mTORC1 appears to be activated in almost all patients at diagnosis of AML. Inhibition of mTORC1 did not differ based on response, suggesting that AML cells may have redundant signaling pathways that regulate chemosensitivity in the presence of mTORC1 inhibition