Panelists:Rafael Bejar MD, PhD, UCSD Moores Cancer Center; Elias Jabbour, MD, MD Anderson Cancer Center; Rami S. Komrokji, MD, Moffitt Cancer Center; Ruben A. Mesa, MD, FACP, Mayo Clinic Cancer Center
Ruben A. Mesa, MD, FACP: Rami, you’re clearly at a wonderful cancer center, the Moffitt Cancer Center. As we think about particularly trying to care for these patients, trying to prevent infections, trying to create active preventions, clearly, a multidisciplinary approach can be key, not only in your center, but even across centers. We try to involve a variety of people. Give us a sense of the sort of multidisciplinary team that might be involved in caring for these patients.
Rami Komrokji, MD: I think that’s a key for the management, and Eli touched base on this, that AML treatment so far has been really centralized to academic centers where there are leukemia services. There is definitely a learning curve or experience from the team. So, in our unit, the nurses are treating leukemia all the time. They are familiar with the signs of complications, the infection. When we get a new drug approved, we get education for all the team on that. So we have our main team: that’s the first team, the hematological team. We always have infectious disease colleagues hand-in-hand with us and those patients. In our place, every leukemia patient that’s coming in is seen by the infectious disease people. They follow them, we discuss the cases together. Sometimes we see them together, and they are really key in the management of patients during the intensive chemotherapy. We need their help tremendously at that point. We do have a palliative team, pain service, that also is on board with us. We get a dietitian and nutrition team to see those patients up front. Our colleagues in transplant sometimes will come early on when we identify those patients, because you could take advantage of the month where the patient is in the hospital to go for the HLA [human leukocyte antigen] typing. We have a social worker that actually gets involved and sees those patients. So I think there are so many people that work together on this and I think it’s a key, although we tend to think that hematological malignancies do not have a multidisciplinary team. But in the setting of leukemia, there is really a huge effort that goes behind the scenes taking care of those patients.
Elias Jabbour, MD: To add to Rami: these patients, when we treat them, we induce them at our center, but then they just stay for their lives with us, correct? We want to give them the first course. Maybe for the second they want to work with the community physicians in the local hospitals, so they have to go back and forth. And communication between those physicians and us is really crucial. We’re dealing with severe problems, because we are all experts, and we have a multidisciplinary approach in our hospitals. But, for example: if I give somebody decitabine, and they go home and they catch an infection. So what do I do at home? And then I get the call from the doctor. What do I do? Sometimes they don’t want to do anything because they’re scared. Maybe I’ve given the drug, it caused liver problems. He will call me, ‘I have your patient on ponatinib. Can I give him these azoles, yes or no?” So we are establishing a network like all of us in Houston, in Texas, or other areas where we’re communicating our protocols, our standard of care for them. If they can apply them for somebody, that’s fine. If there’s a problem, we’ll bring them back. Obviously, somebody on clinical trials, we bring them in. Otherwise, we try to communicate and give advice to the infectious disease locally, to the community oncologist, to the GPs who are handling this daily stuff. As an example: somebody on decitabine maintenance who goes home had an infection. What do I do? So they start with an antibiotic and anti-fungal therapy, and then we’ll bring them back later on if they are not getting better.
Ruben A. Mesa, MD, FACP: So, clearly, it takes a village. It really takes a team. I think you mentioned before, even the aggressive approach of some baseline scanning I think is prudent, particularly with people with a complicated course. And I would say also you need pulmonologists, sometimes dermatologists in terms of cutaneous infections. Other things can be clearly helpful.
Ruben A. Mesa, MD, FACP: Well, I think this has been a great discussion. You guys have really showed a tremendous amount of experience, wisdom, guidance, and clinical expertise. This has really been a pleasure. We’ve discussed a lot of information on the latest advances in treatment and supportive care for patients with AML. To close, I’d like to get final thoughts from each of the panelists. Dr. Bejar.
Rafael Bejar MD, PhD: I think this is an exciting time for AML. We’ve had a long stretch of time where we didn’t have new therapies to offer patients, and now our pathobiological understanding of these disorders is coming to fruition. We’re getting more therapies that look very promising on the horizon, and we have an entirely new avenue to explore with these immune therapies. I think that we’re at a transition point for AML and it’s an exciting time to be in the field.
Ruben A. Mesa, MD, FACP: Dr. Jabbour.
Elias Jabbour, MD: I definitely echo Rafael’s statement. Lots of excitement, new drugs. I still reiterate we need to treat these patients in the hand of experts and clinical trials.
Ruben A. Mesa, MD, FACP: Dr. Komrokji.
Rami Komrokji, MD: Yeah, I think it’s very exciting. I’m looking forward to the presentation today at the plenary session to hear the data on the new drug that hopefully we approved, and prove the outcome. I think it’s always important to maximize the benefit of the current available therapies. We discussed a lot about the best supportive care, so fine tuning that is very important. But I think in the coming few years, as we understand more the biology, we’ll have more options for treatment, more transplant patients, and targeted therapy So, this is really a very exciting time.
Ruben A. Mesa, MD, FACP: I would agree. I’m very excited and very hopeful. I think we realize that even in acute myeloid leukemia, you’re really talking about dozens and dozens of different phenotypes, subsets, individual variabilities, not only around the leukemic clone itself, but their own health, their predisposition to infection, their cardiac status, their comorbidities. It really is an incredibly complicated area, but I think we’re making some really genuine strides, and there’s some exciting data that is really helping to move things forward. So, on behalf of our panel, we thank you for joining us, and we hope that you found this peer exchange discussion to be useful and informative. Thank you.