Immunotherapy, Non-Cytotoxic Therapy, and the Importance of Case Reports

We spoke with Maurie Markman, MD, Editor-in-Chief of Karger’s journals Oncology and Case Reports in Oncology, about new treatments and prospects in the field of oncology.

maurie markman

Maurie Markman, MD became the Editor-in-Chief of Karger’s journal Oncology in 2007 and is the founding Editor of the journal Case Reports in Oncology.

He is President of Medicine & Science at Cancer Treatment Centers of America® and Chief Clinical Officer for CTCA Health. For more than 30 years Dr. Markman has been engaged in clinical research in the area of gynecologic malignancies, with a particular focus on new drug development and exploring novel management strategies in female pelvic cancers.

Among other distinctions, he was named by OncLive® to an elite group of 21 inductees of the 2018 Giants of Cancer Care® recognition program. The program celebrates pioneers, innovators and leaders who have made remarkable achievements in oncology research and clinical practice. Dr. Markman was selected by his peers in recognition of his contributions in gynecologic cancers.

At Karger, we are very happy to count this distinguished researcher among the Editors-in-Chief of our journals. We have asked him a few questions about himself and his views on publishing.

Can you tell us a little about yourself? How did you become interested in oncology?

While serving as an internal medicine resident at Bellevue Hospital/New York University Medical Center I was fascinated by both the incredible evolving revolution in our understanding of the biology of cancer and at the same time the major challenges and opportunities associated with caring for cancer patients. I decided to enter the field of medical oncology and hematology and I have never regretted this decision. After serving as a Chief Medical Resident I spent two years working at the U.S. National Institutes of Health and completed a fellowship in medical oncology and hematology at Johns Hopkins University Medical Center. It has been a wonderful experience, both in patient care and clinical research.

What challenges and developments can we expect to see for this field in the next few years?

Probably the most important developments will be in the area of novel anti-cancer pharmaceutical agents. The management of a number of malignancies has been transformed over the past decade with the introduction of effective molecularly-targeted therapeutics and immunotherapy (checkpoint inhibitors). It is likely this trend will continue with combination non-cytotoxic therapy (therapy that does not aim  to directly kill cancer cells) becoming more prominent in disease management. One critical issue for the future will be strategies to determine how to optimally utilize these very expensive drugs, especially as it is increasingly recognized that advanced cancers are being converted into more chronic disease processes where effective and tolerable treatments may be delivered over a period of “years”, rather than “months”.

As the Editor-in-Chief of the journal Oncology, you introduced the section “Reducing the Worldwide Burden of Cancer”. What was your motivation to include this section and what kind of submissions would you like to see in this section?

It is well-recognized that cancer is a worldwide problem and certain cancers are actually far more common in the developing world. The idea was to focus on cancer developments in these countries and to include investigators who may not otherwise have the opportunity to publish their work in a journal of the quality of Oncology.

You are also the Editor-in-Chief of the journal Case Reports in Oncology. In your opinion, what is the role of case reports in scientific publishing?

This is an important but complex question. Clearly, a single case summary, no matter how well written or documented, should never be seen as providing the level of data observed in a well-designed prospective clinical trial. However, case reports can be extremely helpful in individual management of an uncommon clinical scenario or may provide unique insight into a novel molecular mechanism that should be further investigated in a clinical trial. It is critical to emphasize that such case reports are rarely accepted in major oncology journals as there is always competition for limited space. An online journal devoted specifically to communication of cases seemed to be the appropriate venue, and when Dr. Karger suggested this opportunity to me I was delighted to assume the role of Editor-in-Chief of this novel oncology communication venue.

Thank you for giving us insight into your motivation to become an oncologist and into your views on publishing cancer research.

Read the articles from the section “Reducing the Worldwide Burden of Cancer”.

Also, check out the latest publications from the journals “Oncology” and “Case Reports in Oncology”.

Interested in reading other interviews with our Editors-in-Chief? Check out the interview with Editor in Chief of our journal Gynecologic and Obstetric Investigation, Prof. Dr. med. Thomas M. D’Hooghe. 

Managing Patient Expectations: the Example of CAR T-cell Therapy

With recent CAR T-cell therapy approvals in leukemia and lymphoma, there has been a lot of coverage in both traditional media and social channels about the successes of this groundbreaking new therapy. Specifically developed for each individual patient, CAR T-cell therapy is a complex and indeed risky procedure that involves reprogramming the patient’s own immune system cells, which are then used to target their cancer.

It has been shown in trials to cure some patients, even those with advanced disease where more conventional treatments have failed. However, while early data are promising, patients need to be aware that there is no guarantee that the treatment will work. It is therefore critical that healthcare professionals manage patient expectations so that they can make informed decisions about their care.

The Clinical and Patient Markets division at Karger publishes the free- to- access Fast Facts series, which seeks to address educational gaps in healthcare and improve the communication between the clinician and patient. As part of the development for a new clinical handbook in the Fast Facts series, experts Dee Moloney and Richard J. Buka discuss helpful strategies that healthcare professionals can utilize to manage patient expectations.

While these strategies are presented here in the context of CAR T-cell therapy, the principles can of course be easily transferred across many different disease states, particularly when managing patient expectations concerning innovative therapies.

Be Confident in Delivering Clear, Frank Discussions

Eligible patients and their caregivers need to be given a realistic picture of what to expect before treatment starts, including a clear explanation of what CAR T cells are and a frank discussion about:

  • the benefits versus the risks
  • how long the treatment process will take, and the steps involved
  • what venous access/central venous access may be required
  • the possibility of CAR T-cell manufacturing failure
  • the likely side effects, their severity, and possible admission to ICU
  • possible outcomes of treatment
  • how long the patient will need to stay in hospital
  • the level of caregiver support required (availability and proximity to treatment center)
  • the practicalities of travel and accommodation during treatment
  • the need for long-term (lifetime) follow-up
  • the unknown long-term side effects, given the lack of long-term follow-up data
  • the cost (if applicable)

Patients must be given time to digest information about the whole treatment process, and the information provided must be presented at a level that the patient can understand.

Engage With Your Patients – Ask Simple but Useful Open Questions

Showing compassion and empathy, asking open questions to engage the patient in conversation, and taking the time to listen are important interpersonal skills that healthcare professionals need to utilize before and during treatment and at follow-up consultations. Simple but useful open questions to ask include:

  • How has your mood been?
  • Is anything in particular worrying you right now?
  • How are you coping?
  • How do you think your partner/ family are coping?
  • How do you feel about this treatment?

It is useful to ask family members and other caregivers these types of questions as well, and to gauge their understanding and expectations of the CAR T-cell treatment process.

Careful Planning for a Better Patient Experience

Assessing a patient’s understanding of the treatment process and managing their expectations can help to alleviate concerns for the patient and their family members. If the patient’s concerns are addressed early, then a tailored treatment plan can be put in place ahead of time. This may include the use of alternative medications to help manage uncontrolled symptoms, for example administration of anti-anxiety medications on the day, and referrals to specialist services for pain control and psychological support. Needle- and/or blood-phobic patients will require extra measures: for example, the apheresis team can advise the patient when they ‘can look’, and can hide needles, cannulas and blood in tubing from the patient’s line of vision.

Recognize the Importance of Psychological and Emotional Support

Both are important for the patient and their caregivers when preparing for, during and after CAR T-cell therapy. Although there is limited research, feedback from patient- reported outcome questionnaires have shown that patients experience increasing anxiety throughout the CAR T-cell therapy process, which is slow to alleviate problems even when they respond to treatment.

Specific fears reported by patients before CAR T-cell therapy include:

  • the anxiety about having cells collected
  • the severity of expected side effects
  • the potential need for intensive care
  • the possibility of the treatment not working
  • the unknown recovery times from side effects
  • the possibility of relapse after an initial response within the first year

Nurses especially, can provide much-needed support throughout the patient’s CAR T-cell therapy journey. Referrals for counseling or other psychological support may also be offered. For centers that have established protocols to enable outpatient monitoring, patients must be given access to a healthcare professional and an out-of-hours emergency contact number that can be used at any time, so that immediate review or emergency admission can be initiated by staff experienced with CAR T-cell therapy.

Further Reading

For further reading, please do take advantage of two free- to- access Fast Facts eBooks on CAR T-cell therapy, providing further insights, experiences, and expertise from field-leading practicing experts – Ankit J. Kansagra (USA), Richard J. Buka (UK) and Dee Moloney (UK).

Fast Facts: CAR T-Cell Therapy in Diffuse Large B-Cell Lymphoma – Karger Publishers

Book Cover "Fast Facts: CAR T-Cell Therapy in Diffuse Large B-Cell Lymphoma" published by Karger Publishers

Fast Facts: CAR T-Cell Therapy – Karger Publishers

Book cover "Fast Facts: CAR T-Cell Therapy" published by Karger Publishers

Knowledge Defeats Fear! How We Contribute to Patient-Centricity

Being informed about one’s health helps against anxieties, enables better communication between healthcare professionals and patients, and creates possibilities for patients to better live with their disease. Our new children’s book is a good example of how a complex topic like leukemia can be explained to the youngest patients.

Patient empowerment is a central keyword in healthcare systems that are changing globally towards a patient-centric model. Putting the patient at the center of everything health-related seems logical but has not been a reality for many years. It’s been less than a decade since healthcare experts and different stakeholders of the healthcare ecosystem began remodeling their view on how healthcare should work – putting the main characters at the center of the stage instead of financial transactions.

Building Knowledge

Empowered patients – better yet, an empowered public – are able to play an active role in healthcare. The positive effects of better-informed patients are easy to understand: avoiding disease where possible, giving patients the possibility to better live with their disease, and enabling better communication between patients and healthcare professionals all have a positive impact on the healthcare system. Building knowledge is at the core of patient empowerment. However, educating patients and the public is not as simple as it might sound. Who’s responsible for this task? Who is to trust with the information shared? Where can such information be found and accessed?

Reliable and Up-to-Date Information

We saw good reasons to take on this role ourselves as a publisher and decided to dedicate a whole department to patient information and to de-mystify diseases, work against fake news, and spare people the anxieties of diagnosis by “Dr. Google”. As a publisher in the health area, we have access to the latest research in health sciences and abundant contacts to experts, medical associations and societies, and industry. This positioning in the healthcare ecosystem enables us not only to publish reliable, well-curated content for patients, caregivers, and the interested public, but also to collaborate with strong partners to distribute our patient information.

Knowing Your Audience

Each topic calls for a different way and format of communication to be helpful for our audience. We always need to consider age, level of education, regional factors, and others to make sure we “hit the right tone”. This was especially important for the children’s book “Frisst ein Krebs die Haare auf?” (engl.: Does the cancer eat my hair?). The book tells the story of the little leukemia patient Ela from the girl’s point of view. Written and illustrated by herself as project for her highschool diploma the young author Grit Brunner delivered a remarkable wealth of information for children with leukemia with her manuscript.

Book cover of "Frisst ein Krebs die Haare auf?", a picture book about leukemia

A picture book about leukemia. Text and illustrations by Grit Brunner.

Realizing this project not only gave us the opportunity to expand our patient portfolio in oncology, but also offered an excellent collaboration with a young talent. This is a project of the heart that we took on because we believe in the power and benefits of knowledge and good information. In this case, we hope to help little patients, their siblings and friends to better understand what leukemia is and what the treatment encompasses.

Publishing information for children is maybe the “supreme discipline” in a field as complex as patient information, where highly technical, scientific facts need to be transferred to a level of common understanding without compromising accuracy and correctness. After all, if young or old: it is always better to deal with something when one is well informed.