In a new report, the American Society of Clinical Oncology (ASCO) highlighted progress that has been made toward reducing disparities in cancer health among sexual and gender minority (SGM) individuals, although they stressed that additional progress is still needed in this area.

, served as an update on ASCO’s 2017 position statement “Strategies for Reducing Cancer Health Disparities Among Sexual and Gender Minority Populations.”

In the 2017 statement, ASCO outlined 5 areas of recommendations aimed at addressing the needs of both SGM patients with cancer and SGM members of the oncology workforce: patient education and support, workforce development and diversity, quality improvement strategies, policy solutions, and research strategies. The authors of the 2023 report noted that significant progress has been made, such as providing recommendations on sexual orientation and gender identity (SOGI) data collection, promoting training focused on SGM disparities in the oncology workforce, supporting research on SOGI data collection, and creating patient support groups and academic resources to serve SGM patients with cancer.

“The [2023] State of Cancer Care in America report was looking at what has been done nationally, and then specifically within ASCO, to address each of these pillars over the past 6 years,” Charles S. Kamen, PhD, MPH, an associate professor of surgery and psychiatry at the University of Rochester Medical Center in New York and cochair of the ASCO Sexual and Gender Minorities Task Force, said. “ASCO convened a task force in 2019 with the specific mission of putting action to the 2017 position statement. Over the past 4 years, we worked to make the pillars of the original vision statement actionable.”

, Kamen, who is the lead author of the new report, discusses the key developments in this area since 2017 and efforts that are planned and underway to further the progress that has been observed in terms of increasing cancer equity in SGM individuals.

: How did you approach this new report and what were some of the key takeaways?

When we wrote the manuscript, we reorganized the 5 pillars from how they were in the position statement to emphasize the ones where there had been the most attention given. The first pillar we [addressed] was about quality improvement and data collection. The main priority that many of us have focused on is collecting high-quality sexual orientation and gender identity data consistently across oncology practices for every patient, every time.

You can’t address a problem you can’t see. If you’re not identifying who in your practices are SGM patients, you can never know if they’re having different responses to treatment, are dropping out of treatment at higher rates, are being offered clinical trials at different rates, or if their partners or caregivers are being incorporated into care differently.

This is also the main thing that groups like the National Cancer Institute are focused on. They released a supplement application opportunity last year to help cancer centers [gather] SOGI data consistently. In the [report], we talked about how the task force created an at-a-glance guide for cancer clinical trialists so they can collect SOGI data as part of that work.

What areas still require improvement and how are they being addressed?

One is having a better body of research. There are still so many unanswered questions that SGM patients confront when they’re entering cancer care. For a transgender patient on gender-affirming hormones who is starting chemotherapy or immunotherapy, it’s unclear whether those hormones can continue or if the hormones should be discontinued while they are undergoing cancer treatment. Right now, it is up to oncologist preference on how the patient is counseled, but it would be great to have actual empirical data to support counseling in one direction or another.

We need to think about incorporating SGM identities as part of how people are looking at pipeline issues, who is getting promoted in the oncology workforce, [and] who’s getting supported and mentored in that workforce. Have you made sure that from clinical trial coordinators all the way up to oncologists, there is a workforce that matches the population that’s being served, [for example]?

The last part of our manuscript was [focused on] highlighting policy initiatives. This is the area where we have seen the most backlash to the progress that has been made. We have moved forward in so many areas of this work, and yet there are so many anti-LGBTQ laws on the books in multiple states and more being voted on every day.

We tried to make the point in the paper that we don’t expect oncologists necessarily to go out and lobby for [SGM issues]. However, looking at local policy is important, too. What is the nondiscrimination policy in your oncology practice, and does it include sexual orientation and gender identity as protected categories that should not be discriminated against? That is also useful, and probably even more useful in states where the state-level policies aren’t very welcoming to SGM individuals.

What are some areas of future study you are interested in regarding SGM disparity research?

Intersectionality [remains] a major issue in this field. This is true both for research and for clinical care. We can’t just think about improving care for SGM patients. If you’re coming in to do health equity work, you need to think about multiple intersecting minority identities. [For example], for Black transgender women, are they being served in a cancer care practice with the same high-quality care as a White cisgender male patient?

It’s especially important to think about SGM health equity because there is so much emphasis on it now. [We need to] use this moment of focus to also talk about how practices are treating individuals who are impoverished, have disabilities, are of racial or ethnic minorities, or have language barriers.

How can clinicians use the findings from this report to improve the care they provide?

[They must] figure out a way to assess sexual orientation and gender identity in [their] patients. Patients don’t necessarily want to have a conversation about this topic; there [are] research [data] showing that SGM, heterosexual, and cisgender patients all prefer to respond to questions about sexual orientation and gender identity on a form. [Clinicians need to] figure out a way where they can work with their intake coordinator or the people who run their patient portal and/or medical records so that patients can complete these demographic items nonverbally on a form.

If you’re going to collect the data, you also have to make sure that your care system is equipped to treat those patients with respect and with the same high-quality care as anyone else. An ongoing fear [of ours] is these data will be collected and then individuals who have biases will use it to actually treat SGM patients worse [than other patients], or [that the data] will get into the hands of a “bad actor” and end up causing more distress and more discrimination. That’s [important to consider]—whether that means making sure that [those who work in] the health care system [are] trained to treat SGM patients well or just having protections put in place for who can and can’t access these data.

[Finally], collecting data without action is useless. If you’re going to go through the effort to collect some data, then make sure that [they are] being used in some way to inform the delivery of care. That doesn’t mean that you have to revise the entire procedure for having an oncology visit to account for someone’s sexual orientation or gender identity; there are very simple changes. [These could include] having scripts in your mind so if somebody pushes back against collecting the SOGI data you’re able to say something like, “We ask the same questions of every patient; it’s just for us to get to know you better. If you’re not comfortable answering any of these questions, you don’t have to.” Make it straightforward and simple.

My big-ticket hope from all of this is that we not only start collecting high-quality SOGI data and use [them] to inform care, but also…improve care for everybody because we’ll have these better ways of talking to patients that don’t assume particular relationships or gender identities or expectations. That’s going to help everybody and make care better for every single patient.

Kamen CS, Dizon DS, Fung C, et al. State of cancer care in America: achieving cancer health equity among sexual and gender minority communities. 

. 2023;19(11):959-966. doi:10.1200/OP.23.00435

Griggs J, Maingi S, Blinder V, et al. American Society of Clinical Oncology position statement: strategies for reducing cancer health disparities among sexual and gender minority populations. 

. 2017;35(19):2203-2208. doi:10.1200/JCO.2016.72.0441

Articles

Charles S. Kamen, PhD, MPH, discusses key developments and efforts that are planned and underway to further the progress that has been observed in terms of increasing cancer equity in sexual and gender minority individuals.

ASCO Special Report Outlines Progress in Reducing Cancer Disparities for LGBTQ+ Individuals

Tumor lysis syndrome is an oncologic emergency that every clinician will likely encounter at one time or another, and managing it requires careful consideration of a number of factors. Using the following case studies, I will highlight some of the unique aspects of TLS management. 

A 32-year-old Hispanic woman presented to the emergency department with 6 weeks’ history of worsening lower back and pelvic pain associated with weight loss, fevers, and night sweats. Initial imaging showed diffuse abdominal-pelvic lymphadenopathy concerning a hematological malignancy. On the patient’s admission, abnormal laboratory results included potassium levels of 5.8 mmol/L, uric acid levels of 9.6 mg/dL, lactate dehydrogenase (LDH) of 1280 U/L, and a creatinine level of 2.3 mg/dL. Complete blood counts (CBCs) revealed a low hemoglobin level of 7.6 g/dL and platelet count of 76000/uL. Further workup revealed highgrade lymphoma indicating Burkitt lymphoma. She received a diagnosis of tumor lysis syndrome (TLS) from lymphoma and was appropriately treated.

TLS is 1 of the most common oncologic emergencies encountered by every resident, fellow, and/or faculty member caring for patients with cancer, and is broadly classified into laboratory and clinical TLS. 

Laboratory TLS is defined as 2 or more abnormal serum values (Table 1), present within 3 days before or 7 days after instituting chemotherapy. Clinical TLS is defined as laboratory TLS plus one or more of the following clinical findings: increased serum creatinine concentration (≥ 1.5 times the upper limit of normal), cardiac arrhythmia/sudden death, or a seizure that was not directly or probably attributable to a therapeutic agent.

The necessity to prophylactically manage TLS stems from the significant complications including acute kidney injury (AKI), cardiac arrhythmia, and death when TLS is untreated or the treatment is delayed. The main preventive treatment options include isotonic intravenous fluids (IVFs) and the use of hypouricemic agents such as allopurinol and rasburicase.

The recommended rate of IVF is 2 to 3L/m2 daily to maintain a urine output of 80 to 100 mL/m2 per hour. Achieving high urine output is thought to improve renal perfusion and minimize the likelihood of uric acid or calcium phosphate precipitation in the tubules. However, close monitoring for fluid overload should be performed, and diuretics can be used if required. 

Allopurinol is a xanthine oxidase inhibitor that prevents the formation of new uric acid, and ideally should be started 2 to 3 days prior to initiation of chemotherapy when possible. The recommended dose of allopurinol is 100 mg/m2 every 8 hours, with a maximum of 800 mg daily, and the dose is reduced by 50% in the setting of AKI to prevent accumulation of allopurinol.

If TLS does not occur, allopurinol can be discontinued within 10 to 14 days of chemotherapy initiation. Febuxostat is another orally available hypouricemic drug that selectively inhibits xanthine oxidase and does not need renal adjustments. It can be used when allopurinol or rasburicase is contraindicated.

In contrast, rasburicase is a recombinant urate oxidase that causes the breakdown of uric acid and rapidly reduces its levels in the serum and is ideal when patients need urgent initiation of chemotherapy and already have elevated uric acid levels. The FDA-approved dosage for rasburicase is 0.2 mg/kg daily for 5 days; however, in practice, single flat doses are commonly used. 

Meta-analyses of studies regarding single-dose rasburicase have determined that a single 3-mg dose is often sufficient to lower and maintain uric acid levels if baseline uric acid is less than 12 mg/dL, and a single 6-mg dose is often sufficient if the uric acid is at least 12 mg/dL.

Our institutional audit of rasburicase usage and outcomes was consistent with these findings. Additional doses can be used if hyperuricemia recurs. The treatment of patients with established TLS is along the same lines as that for preventing TLS along with prompt monitoring of electrolytes and correcting them appropriately. In the era of rasburicase, renal replacement therapy is reserved for those with fluid overload, oliguric or anuric acute renal failure, and persistent electrolyte abnormalities.

A 67-year-old White man was admitted to the hospital for chimeric antigen receptor (CAR) T-cell infusion for his primary refractory diffuse large B-cell lymphoma. On day 2 of the post CAR T-cell infusion, he developed high-grade fevers. He received antipyretics and was started on prophylactic antibiotics after an infectious workup was performed. His fevers continued to worsen, and he received tocilizumab (Actemra) for suspected grade 1 cytokine release syndrome (CRS). His symptoms were better after 2 doses of tocilizumab, and he was discharged on day 7 in a stable condition.

CRS and immune effector cell-associated neurotoxicity syndrome (ICANS) are other common hematological emergencies associated with CAR-T cell therapy and T-cell engaging antibodies. CRS is an acute systemic inflammatory condition associated with fever, hemodynamic instability, and multiorgan dysfunction.

 Laboratory abnormalities include elevated inflammatory markers, C-reactive protein, and ferritin. However, these are nonspecific and can be elevated in other inflammatory and infectious states. Substantial elevation of serum IL-6 levels is a more specific marker of CRS, but the availability is limited to specialized laboratories.

CRS usually occurs with a median onset of 2 to 3 days post CAR T-cell therapy and resolves within 1 week. ICANS has a delayed median onset of 5 days and can last for up to 2 weeks. It can occur concurrently with CRS or as a different syndrome by itself. CRS usually starts with fever (≥ 38.0 °C) and gradually progresses to hypotension. Severe CRS manifests with hemodynamic collapse and increased vascular permeability, leading to peripheral and/or pulmonary edema, renal failure, cardiac dysfunction, and multiorgan system failure. ICANS, on the other hand, can present with mild alterations in mental status to severe neurological dysfunction.

Grading of CRS and ICANS is crucial because it determines the management of the conditions. Criteria are formulated by the American Society for Transplantation and Cellular Therapy (ASTCT). For a quick calculation, we recommend utilizing the CRS and ICANS calculator in the ASTCT mobile application, which postulates the results quickly. It is important to keep in mind that the symptoms of CRS/ICANS must not be attributable to any other cause, especially infection and sepsis.

Initial management of CRS/ICANS includes symptomatic treatment with antipyretics, IV hydration, prophylactic broad-spectrum antibiotics, and antiepileptics, and performing appropriate investigations to rule out CRS/ICANS mimics, especially sepsis and other central nervous system pathologies. Tocilizumab, an IL-6 receptor antagonist, is used for grade 1 or higher CRS and persistent or refractory grade 1 CRS. It has no effect in ICANS because the drug does not pass through the blood-brain barrier.

 It is given intravenously over 1 hour at an 8-mg/kg dose and can be given every 8 hours up to 3 doses, with a total dose not exceeding 800 mg.

Glucocorticoids are the mainstay of treatment for patients with ICANS, but are also considered in persistent grade 1 and rapidly progressive CRS, depending on the type of CAR T-cell product. IV dexamethasone at 10 mg every 6 to 12 hours is the typical glucocorticoid used, and doses can be increased to 20 mg every 6 to 12 hours for rapidly progressive CRS/ICANS. Steroids are continued until the symptoms resolve to grade 1 or less and taper over 3 days. In severe cases of CRS/ICANS, patients who fail to improve after multiple doses of both tocilizumab and steroids may be given methylprednisolone at 2 mg/kg up to 1 g daily for 3 days as a last resort, accepting the fact that this may ablate the CAR T cells. Other agents tried in severe cases include siltuximab (Sylvant), anakinra (Kineret), and etanercept (Enbrel).

Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. 

. 2008;26(16):2767-2778. doi:10.1200/jco.2007.15.0177

Howard SC, Trifilio S, Gregory TK, Baxter N, McBride A. Tumor lysis syndrome in the era of novel and targeted agents in patients with hematologic malignancies: a systematic review. 

. 2016;95(4):563-573. doi:10.1007/s00277-015-2585-7

Lopez-Olivo MA, Pratt G, Palla SL, Salahudeen A. Rasburicase in tumor lysis syndrome of the adult: a systematic review and meta-analysis. 

2013;62(3):481-492. doi:10.1053/j. ajkd.2013.02.378

Yu X, Liu L, Nie X, et al. The optimal single-dose regimen of rasburicase for management of tumour lysis syndrome in children and adults: a systematic review and meta-analysis. 

. 2017;42(1):18-26. doi:10.1111/jcpt.12479

Frey N, Porter D. Cytokine release syndrome with chimeric antigen receptor T cell therapy. 

. 2019;25(4):e123-e127. doi:10.1016/j.bbmt.2018.12.756

Neelapu SS, Tummala S, Kebriaei P, et al. Chimeric antigen receptor T-cell therapy—assessment and management of toxicities. 

. 2018;15(1):47-62. doi:10.1038/nrclinonc.2017.148

Brudno JN, Kochenderfer JN. Toxicities of chimeric antigen receptor T cells: recognition and management. 

. 2016;127(26):3321-3330. doi:10.1182/blood-2016-04-703751

Tumor lysis syndrome (TLS) and cytokine release syndrome (CRS) are two common oncologic emergencies that require careful management. TLS, often seen in patients with hematological malignancies, can lead to significant complications if untreated. CRS and immune effector cell-associated neurotoxicity syndrome (ICANS) are common emergencies associated with CAR-T cell therapy. Both conditions require specific treatment strategies and close monitoring.

Tumor lysis syndrome is an oncologic emergency that every clinician will likely encounter at one time or another, and managing it requires careful consideration of a number of factors. 


Managing TLS and CRS/ICANS: Through the Lens of a First-Year Hematology/Oncology Fellow

African American women not only have the highest mortality rate of any ethnic group in the United States, but also the lowest cause-specific 5-year survival from breast cancer. I am acutely aware of this fact because breast cancer has directly affected multiple women in my family. Though I could write a book about each woman in my family, I hope to provide a brief snapshot of the most impactful memories that inspired my career in breast surgical oncology.

On December 28, 1988, my mom received a diagnosis of stage IV breast cancer 3 months after my maternal grandmother, Mary Emma Mullin, died from the disease. The following day my dad wrote a letter to my mom stating that God told him they would have a son named Adam.

After 2 rounds of chemotherapy, a mastectomy, radiation therapy, and cessation of her menstrual cycle, in addition to advanced maternal age, she discovered she was pregnant. During the pregnancy, one of her physicians suggested an abortion, due to the increased chance of the cancer recurring. My mom chose to continue with the pregnancy, and I was born on June 28, 1991, coincidentally under the astrological sign Cancer.

Her cancer recurred in 2001 and due to complications from chemotherapy, her kidneys failed in 2002. Subsequently, she was placed on disability. I remember her being sad that she could no longer teach, as my mom was a passionate educator. She homeschooled me in eighth grade, and in tenth grade, she coordinated a shadowing experience for me with a urologist in Warner Robins, Georgia.

One day I came home from shadowing Melvin Fussell, MD, and met my mom in the kitchen; she would often try to teach me how to cook and I would decline. I looked at her and said, “When I grow up, I want to be a surgeon.” My mom, who had experienced myriad health issues, smiled, looked at me, and said, “When you become a surgeon, you can operate on me.” I optimistically and naively responded, “By the time I become a surgeon you won’t even need surgery.” In a way, we were both correct.

I was 20 years old when my mom died on September 9, 2011, secondary to sepsis from a dialysis line infection. She was 56 years old.

I remember the holiday gatherings at my Aunt Ann’s house in Albany, Georgia. She had a beautiful home with a large backyard that my cousins and I would play in. A favorite treat that would be waiting for us were soft caramels she kept inside a bowl.

The last distinct memory I have of her is her bald head, as she was lying in the hospital bed and mustering up the strength to whisper a “Hey, baby.” My mom told me that one of her last memories of her sister was Ann saying, “Mal, I wanted to have children.”

I was 5 years old when my Aunt Ann died on March 11, 1996, from metastatic breast cancer. She was 43 years old.

It was always a joy when my Aunt Carolyn would come visit. My mom always seemed to have more energy when she was around. Aunt Carolyn learned she had a 

mutation while I was in medical school. She was preparing to have a double prophylactic 

mastectomy in 2020; however, the COVID-19 pandemic halted this process.

When I was in my chief year of my general surgery residency, Aunt Carolyn informed me that she felt a swollen lymph node in her left armpit. She was hopeful that it was secondary to having recent vaccines injected in her left arm, especially as a bilateral breast MRI earlier that year had not demonstrated any concerning findings.

I went to visit her during the holiday season of 2022, and she invited me to come with her for her biopsy. I was back in Kansas when my Aunt Carolyn called, as a nurse navigator shared the results. It was cancer. My aunt cried for less than a minute. Though I was not in the room with my mother when she received her diagnosis twice, what a full circle moment and honor it was that my aunt would call me to support her at that time.

From that day on, my aunt has demonstrated the power of most cancer survivors. She is determined to not let this defeat her. She continued to train and graduate from a yoga instructor class while she completed neoadjuvant chemotherapy. She underwent surgery in July 2023 and completed adjuvant radiation therapy in September. She is a coauthor of a survivorship book entitled 

and continues to encourage women fighting breast cancer through yoga and volunteering in 3 different cancer foundations. She is 62 years old.

Below are 10 lessons I learned from watching these beautiful women and their battle with breast cancer:

1. Never let a beautiful, sunny day go by without appreciating it.

3. Life is short. Live it to the fullest. 

Be your truest, most authentic self—unless you’re a jerk. In that case, please choose to be someone else.

Mind your business. Change yourself. Change the world.

6. It is only considered a failure once you give up, otherwise it is a lesson. 

Life is about progression, not perfection.

but after a while, give yourself permission to stop looking.

8. The bigger the risk, the bigger the reward, 

and sometimes the outcomes can be miraculous.

Conserve and protect your energy for things and for people that matter.

10. Be courageous. Be strong. Be a queen. 

Be unapologetically great. Be fierce. Live free. Be a warrior and fight like a girl!

It is an honor to serve as a breast surgical oncologist, and I look forward to providing all my patients with the same care I have devoted to my family members.

A breast surgical oncology fellow tells the story of how 3 women
in his family helped shape his career and provide a purpose for his passion.

The Mullin Sisters

The 2023 European Society for Medical Oncology (ESMO) Congress took place October 20 to 24 in Madrid, Spain, with global perspectives on groundbreaking data and practice-altering updates across the gamut of oncology. With hundreds of abstracts presented, we broke down some of the key highlights from the annual meeting that oncology fellows should absorb, and apply to practice, as soon as possible.

One of the most notable highlights from the meeting was the presentation of findings from the phase 3 EV-302/KEYNOTE KN-A39 trial (NCT04223856), presented by Thomas B. Powles, MBBS, MRCP, MD. Data from the study demonstrated that the combination of the antibody–drug conjugate (ADC) enfortumab vedotin-ejfv (Padcev) and the PD-1 inhibitor pembrolizumab (Keytruda) led to a significant survival benefit compared with platinum-based chemotherapy in patients with treatment-naive locally advanced or metastatic urothelial cancer regardless of cisplatin eligibility.

At a median follow-up of 17.2 months, the median overall survival (OS) in the combination arm (n = 442) was 31.5 months (95% CI, 25.4-not reached [NR]) compared with 16.1 months (95% CI, 13.9-18.3) in the chemotherapy arm (n = 444), conferring a 53% reduction in the risk of death (HR, 0.47; 95% CI, 0.38-0.58; 

< .00001). Additionally, the median progression-free survival (PFS) was 12.5 months (95% CI, 10.4-16.6) vs 6.3 months (95% CI, 6.2-6.5), respectively (HR, 0.45; 95% CI, 0.38-0.54; 

< .00001). The respective objective response rates (ORRs) were 67.7% (95% CI, 63.1%-72.1%) vs 44.4% (95% CI, 39.7%-49.2%).

“The results showed a dramatic increase in PFS. There was a 55% reduction in the risk of progression compared with chemotherapy, which is somewhat unprecedented,” Powles, the director of Barts Cancer Centre at St Bartholomew’s Hospital in London, England, said in an interview with 

. “But more importantly, we also showed an over 50% reduction in the risk of death with a hazard ratio of 0.47, and we’ve not previously managed to beat first-line chemotherapy in any trial in unselected first-line urothelial cancer. This is a big step in that direction.”

In breast cancer, findings from the phase 3 TROPION-Breast01 trial (NCT05104866) showed that the TROP2-directed ADC datopotamab deruxtecan (Dato-DXd; DS-1062a) led to a clinically meaningful improvement in terms of PFS compared with chemotherapy for the treatment of patients with hormone receptor–positive, HER2-low or -negative metastatic disease.

The trial met the coprimary end point of PFS; the median PFS in the Dato-Dxd arm (n = 365) was 6.9 months (95% CI, 5.7-7.4) compared with 4.9 months (95% CI, 4.2-5.5) in the chemotherapy arm (n = 367; HR, 0.63; 95% CI, 0.52-0.76; 

< .0001). In terms of the other coprimary end point of OS, study authors noted that these data are not yet mature at a median follow-up of 9.7 months. However there was a trend toward the investigational arm vs the control arm (HR, 0.84; 95% CI, 0.62-1.14).

“We are seeing more and more topoisomerase 1-[directed] ADCs and we don’t have enough data yet to understand how to sequence them, but at the same time having more available agents is always a good thing,” Paolo Tarantino, MD, a researcher at the European Institute of Oncology in Milan, Italy, and clinical research fellow at Dana-Farber Cancer Institute in Boston, Massachusetts, said in an interview with 

. “We know that these patients do require better treatment. These are patients that we mostly treat with chemotherapy and now in just a few years we have [fam-trastuzumab deruxtecan-nxki], sacituzumab govitecan, and now potentially Dato-DXd.”

Dato-DXd made waves in another tumor type during the meeting. The agent displayed encouraging efficacy in patients with advanced or metastatic non–small cell lung cancer (NSCLC) in the phase 3 TROPION-LUNG01 study (NCT04656652). Findings showed that patients treated with the ADC (n = 299) experienced a median PFS of 4.4 months (95% CI, 4.2-5.6) compared with 3.7 months among patients who received docetaxel (n = 305; HR, 0.75; 95% CI, 0.62-0.91; 

= .004). However, patients with squamous histology did not experience a PFS benefit with Dato-DXd (HR, 1.38; 95% CI, 0.94-2.02).

“As a coinvestigator in the study, it was really exciting to see [these results] out there,” Jacob Sands, MD, associate oncology medical director of the International Patient Center and a physician at Dana-Farber Cancer Institute, and an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts, said in an interview with 

. “The benefit that we are seeing in nonsquamous NSCLC is impressive; 

we are seeing a clear separation of the PFS curves. The squamous cell cohort didn’t look the way we had hoped and it raises a lot of questions [about] what to do within this patient population.”

Findings from another phase 3 study, the MARIPOSA trial (NCT04487080), showed that the bispecific antibody amivantamab (Rybrevant) plus the EGFR-directed tyrosine kinase inhibitor lazertinib displayed a clinically meaningful improvement in PFS compared with osimertinib (Tagrisso) in patients with treatment-naive, 

-mutated NSCLC. At a median follow-up of 22.0 months, the median PFS was 23.7 months (95% CI, 19.1-27.7) vs 16.6 months (95% CI, 14.8- 18.5) in the combination and the osimertinib arms, respectively (HR, 0.70; 95% CI, 0.58-0.85; 

< .001). Study authors concluded that their results support the combination of amivantamab and lazertinib as a new standard of care (SOC) for patients with 

-mutated advanced NSCLC in the frontline setting.

In another potential standard-of-care update, this time in locally advanced cervical cancer, findings from the phase 3 INTERLACE trial (NCT01566240) showed that the addition of platinum-based chemotherapy prior to chemoradiation conferred PFS and OS benefits vs chemoradiation alone in patients with locally advanced cervical cancer. In the investigational arm (n = 250) the 3- and 5-year PFS rates were 75% and 73%, respectively, compared with 72% and 64% in the chemoradiation alone arm (n = 250; HR, 0.65; 95% CI, 0.46-0.91; 

= .013). Additionally, patients who received induction chemotherapy prior to chemoradiation experienced a reduced risk of death of 39% vs those who received chemoradiation alone (HR, 0.61; 95% CI, 0.40-0.91; 

“This trial has taken a long time and we are very happy to see that an academic trial can result in an OS benefit,” Ignace Vergote, MD, PhD, chairman of Leuven Cancer Institute and head of the Department of Obstetrics and Gynecology and Gynecologic Oncology at Catholic University of Leuven in Belgium, said in an interview with 

. “We did not really expect it because [data from] all of the earlier trials and metanalyses of neoadjuvant chemotherapy prior to chemoradiotherapy were negative.

But a [previous] subgroup analysis showed that when the induction chemotherapy was given in short courses followed by radiotherapy quickly after…there might be a benefit. That’s exactly what was presented in INTERLACE. The OS difference was substantial, but it’s difficult to interpret because we have [data from] other trials, such as KEYNOTE-A18.”

The phase 3 KEYNOTE-A18 (NCT04221945) trial, which also enrolled patients with locally advanced cervical cancer, evaluated the addition of pembrolizumab to chemoradiotherapy. At a median follow-up of 17.9 months (range, 0.9-31.0), patients who received pembrolizumab plus chemoradiotherapy (n = 529) experienced a 2-year PFS rate of 67.8% compared with 57.3% in the placebo/chemoradiotherapy arm (n = 531; HR, 0.70; 95% CI, 0.55-0.89; 

= .0020). Although OS data were only 42.9% mature, a favorable trend toward the pembrolizumab arm was observed (HR, 0.73; 95% CI, 0.49-1.07).

Study authors concluded that their findings suggest that pembrolizumab to chemoradiotherapy could be considered as a new SOC for patients with newly diagnosed, previously untreated, high-risk locally advanced cervical cancer.

The ESMO Congress held a notable update in colorectal cancer (CRC). The phase 3 CodeBreak300 trial (NCT05198934), which evaluated sotorasib (Lumakras) plus panitumumab (Vectibix) compared with SOC in patients with chemorefractory 

G12C–mutated metastatic CRC, met its primary end point of PFS. The study randomly assigned patients 1:1:1 to receive sotorasib 960 mg daily plus panitumumab (n = 53), sotorasib 240 mg daily plus panitumumab (n = 53), or investigator’s choice of trifluridine/tipiracil (TAS-102; Lonsurf) or regorafenib (Stivarga; n = 54). CodeBreak300 was the first phase 3 trial to examine a 

G12C inhibitor in combination with an anti-EGFR antibody in chemorefractory metastatic CRC.

Additionally, both dose levels of sotorasib plus panitumumab were superior to investigator’s choice of TAS-102 or regorafenib in terms of PFS; patients in the 960-mg and 240-mg groups experienced a median PFS of 5.6 months (95% CI, 4.21-6.31) and 3.9 months (95% CI, 3.71-5.75), respectively, compared with 2.2 months (95% CI, 1.94-3.91) in the SOC arm. Treatment with the combination led to a reduction in the risk of progression or death compared with SOC of 51% (HR, 0.49; 95% CI, 0.30-0.80; 

= .006) and 42% (HR, 0.58; 95% CI, 0.36- 0.93; 

= .03), in the respective investigational arms.

Finally, in the hematologic malignancies session, investigators presented findings from the phase 1/2 EVICTION trial (NCT04243499), which examined the novel anti-BTN3A monoclonal antibody ICT01 in patients with hematologic malignancies for whom the available standard of care was not successful. ICT01 employs a novel therapeutic approach in which it activates γ9δ2 T cells, which has been shown, both in vitro and in vivo, to kill acute myeloid leukemia (AML) blasts and lymphoma cell lines.

Findings from EVICTION showed that among patients with diffuse large B-cell lymphoma (DLBCL; n = 1), follicular lymphoma (n = 1), and AML (n = 24), 1 partial response (PR) was observed in DLBCL and 3 cases of stable disease (SD) were reported in patients with AML. In 10 efficacy-evaluable patients at week 8, the disease control rate was 30%, with 1 PR and 2 instances of SD occurring in DLBCL and AML, respectively.

Enrollment is underway for the phase 2a expansion portion of the study in the United States and Europe. Phase 2a will evaluate the combination of ICT01, azacitidine, and venetoclax (Venclexta) in patients with newly diagnosed AML. 

The 2023 ESMO Congress took place October 20 to 24 in Madrid, Spain, with global perspectives on groundbreaking data. We break down some of the key highlights from the annual meeting that oncology fellows should absorb, and apply to practice, as soon as possible.

What Fellows Need to Know: Key Takeaways From ESMO 2023

It is never too early to think about interviewing for your next opportunity. Even if you have already committed to your next career move, learning how to interview will serve you well as you may be considered for different positions within the organization.

Interviews can be incredibly stressful. But truthfully, it is about knowing yourself and preparing for certain questions. I find it helpful to reframe the interview process as a conversation (rather than an examination) between 2 people about something you are an expert in: yourself.

In addition to self-reflection, it remains important to understand the values, the mission, and the goals of the organization of which you aspire to be a part. Read the mission statement and the credo. The ability to demonstrate that your vision and core values align with those of the organization is truly what an interview is about. Organizations are also looking to evolve and grow. The ability to demonstrate your willingness to embrace an organizational growth endeavor can also differentiate you from other candidates.

There are several common topics that you should be prepared for in any interview:

Interviewers often ask you to tell them about yourself and to describe your background.

When answering this question, think about the factors that have influenced your life and made you the physician you are. This is not a question that requires you to verbally recap your CV. The interviewer wants you to cogently describe what influences brought you to this point in your career and how your past experiences guide your present aspirations.

Interviewers may ask why you are applying to their organization

Refrain from using general statements such as “because you have cutting-edge research and clinical care.” If someone in particular asked you to apply, then mention their name. Again, it is important to show that you have researched the organization and that your goals align with those of the organization. Ultimately, this should be the reason that the job resonates with you. Although geographic desirability may be a component of the answer, it is not a sufficient stand-alone reason.

Interviewers also like to see how you handle pressure

They may ask you a question about your style for handling high patient volumes, busy call nights, or funding pressures, depending on the type of position you are interviewing for. Regardless, they are interested in concrete examples of how you rise above the chaos of practicing hematology and oncology to deliver the best care or work product possible.

Organizations are very interested in teamwork

Teams do not solely comprise physicians, but can also be composed of nurses, support staff, allied health professionals, and so on. Think about your style and be able to discuss an experience working in a high-functioning team and an experience working in a dysfunctional team. Avoid discussing individuals but instead, keep the focus on yourself and what you took learned from the experience.

Prepare questions for the interviewer that are not generic

Avoid bland, nonspecific questions that could apply to any organization. As a job candidate, you should demonstrate a mature sense of inquiry that is tailored to the opportunity. Depersonalized questions, such as “What changes do you expect next year?” often indicate a lack of knowledge about the institution and an underdeveloped sense of inquiry. If you are looking to understand what changes may occur, try to be more specific and say something like, “I see that there are multiple construction areas around the medical center. What is the organization’s plan to expand its hematology-oncology footprint in the community?”

In addition to anticipating questions, other items to consider include your physical appearance for an interview. It is important to make eye contact, to demonstrate open and engaged listening skills, and to dress professionally. I will never forget the interviewee who wore a short-sleeved polo shirt for a faculty job interview on Zoom. He may have said many wonderful things, but the disrespect he showed for the interview process overshadowed any impactful conversation.

Be cognizant of how you interact with the office or administrative staff; it holds great import regarding your ultimate ability to receive a job offer. I remember interviewing fellow candidates who seemed fantastic during the interview session, but were dismissive and rude to our staff. Their inability to interact respectfully with someone who was hierarchically different in the organization ultimately influenced our willingness to hire them, despite their research potential.

Finally, and especially if you plan to stay in the same organization in which you are training, your interview day starts the first day that your fellowship starts. Every day is an opportunity to make a great impression.

Jill Gilbert, MD, is a professor of medicine and director of the Hematology/Oncology Fellowship Program at Vanderbilt University Medical Center in Nashville, Tennessee. 

Vol. 15/No. 4 | Oncology Fellows

ASCO Special Report Outlines Progress in Reducing Cancer Disparities for LGBTQ+ Individuals

Managing TLS and CRS/ICANS: Through the Lens of a First-Year Hematology/Oncology Fellow

The Mullin Sisters

What Fellows Need to Know: Key Takeaways From ESMO 2023

The Heart and Soul of a Job Interview