Tag: msk

How do patients enroll in clinical trials (informed, eligibility etc.)?

Friday, May 24, 2019

TL;DR: After a busy hour as “Doctor of the Day,” Dr. Marciscano and I met with seven patients in his clinic. I learned more about the process behind how patients enroll in clinical trials and treatment for post radical prostatectomy biochemical recurrence.

Arriving at the 67th street entrance of MSK around 8, I took the elevator up to the third floor. Dr. Marciscano was covering for one of his colleagues as “Doctor of the Day; (DOD)” essentially, he would be responsible for approving patients for their daily radiation treatments, reviewing images before treatment, and addressing any clinical issues that may arise. Although the frequency varies at different locations, Dr. Marciscano explained that he is DOD around three times every six months in New York. As DOD, he would cover that entire floor of radiation treatment for all kinds of patients for the entire day.

While at first it was a little bit crazy with plenty of multitasking on Dr. Marciscano’s end (sending and responding to emails, following up on a couple of problems), the pager soon fell silent (probably as Memorial Day weekend was coming up), and we had a quick breather. During this time, we discussed some of the problems that had arisen that morning.

• Creatinine, a chemical waste product from muscle metabolism, is typically excreted in the urine as healthy kidneys filter this chemical from the blood. An increased level of creatinine in the blood means that the kidneys may not be functioning correctly. Unfortunately, with poorly functioning kidneys, the contrast agents for the CT scan (e.g.) will not be cleared from the body efficiently and effectively, leading to prolonged exposure and a higher chance of kidney damage.

We also reviewed some images taken right before a patient’s treatment together; this is another important aspect of radiation therapy (prior to today, we had reviewed treatment planning/contouring and dose approval) – hence the name image-guided radiation therapy (IGRT). The images generated are essentially low-quality X-rays and typically only show the bones. This ensures that the patient’s cancer is lined up with the previously established treatment plan and only the cancer is being targeted with high doses of radiation.

Around 9, we headed up to the fourth floor to prepare the notes for his patients in clinic. This time for clinic, Dr. Marciscano asked me to take notes on patient’s symptoms and their plans for treatment; this was a great way for me to process all the information I heard throughout the day. We met with a total of seven patients that day (technically eight, as he had one patient left when I left around 4:20), ranging from status checks to newly diagnosed patient meetings.

• We discussed cases where there was a relapse shortly after surgery (post radical prostatectomy, meaning the prostate was removed) and post-operative management involving the combination treatment of radiotherapy and ADT (androgen deprivation therapy aka hormonal therapy). While these patients no longer have a prostate, their rising PSA levels post-surgery indicate a biochemical recurrence. In this situation, microscopic prostate cancer cells may still be sitting in the prostate fossa (where the prostate once was) or in the lymph nodes – too small to see on imaging, but still secreting detectable levels of PSA.
  • In these cases, it is important to use systemic treatments like hormone therapy in addition to the localized radiation therapy. Hormone therapy shuts down testosterone production and effects (as Dr. Marciscano describes, the fuel to the fire that is prostate cancer) often administered as daily oral pills and/or injections.
• For patients with unfavorable intermediate-risk prostate cancer (4+3 Gleason), we reviewed a couple of treatment options, ranging from localized radiation therapy to radiation + ADT or brachytherapy + radiation for an extra boost.
• During status checks, we discussed next steps for the patients – both of whom were doing very well in their treatments – and any side effects that they might be having.

Another important aspect of patient care is to offer the opportunity to participate in a clinical trial, if interested/willing and eligible. We consented patients to a phase II trial seeking to improve upon the current standard for post-operative management for prostate cancer with ADT + RT. This is a multi-institutional study also involving clinical investigators at the Dana-Farber Cancer Institute. Before signing consent for enrollment, patients were educated on the two “arms” of the trial with MSK research representatives describing the standard or care and experimental arms. After the patient provided their consent for participation, all of the patients medical history and medications are carefully reviewed by the research team to ensure that they are eligible and safe to enroll on the trial.

Proof of the valuable relationship between physician and patient – one of Dr. Marciscano’s patients generously gave a book to me to read after only having met once before in another status check. Dr. Marciscano clearly connects very well with his patients – a goal that I aspire to achieve if I choose to pursue a medical career. I can’t wait to dive into the book!

Overall, it was yet another interesting and busy day in clinic. I got a little taste of what enrolling in clinical trials looks like, did not get lost in the hospital (yay!), and learned a lot about the future of prostate and kidney cancer treatments!

First day in clinic!

5/10/19 pt. 2: clinic #1.

First day in clinic!

Friday, May, 10, 2019 (pt. 2)

TL;DR: We saw around seven patients in total, ranging from those with newly diagnosed localized disease to status checks (ongoing treatment) to metastatic disease – mostly for prostate cancer. As I shadowed Dr. Marciscano and sat in on patient meetings, I was able to learn about prostate cancer and the cutting-edge treatments offered at MSK.

The day started off bright and early as I headed into the city on the 6:45 AM commuter bus with my dad, getting to New York around 7:45. From Port Authority, I took the “shuttle”/subway to Grand Central and another subway (the 6) from Grand Central to the 68th/Hunter College station uptown. After a short walk, I made it to MSK’s main campus, 1275 York Avenue, ready to start the day around 8:15.

One of the first conversations Dr. Marciscano and I had (in fact, in a call prior to clinic that day), was about his schedule. Because he holds clinic in both Monmouth and New York, he splits his days up between the two locations. In addition, rather than having a little bit of clinic every day, he arranges his schedule to see all his patients on Fridays (NY) – and occasionally Wednesdays (NY) – and Saturdays (Monmouth). He uses the other days to catch up with administrative work, treatment planning (which I’ll get into in the next post), and pursue research projects. As he explained this schedule, I started to realize that doctors do not only see patients. They may also pursue research on the side (typically through clinical trial work), whether it be lab work or retrospective studies. Most importantly, he advised, it’s all about finding where your passion lies (in the lab or in the clinic) and developing a satisfactory balance between the two. (MD life advice #1!)

Once I got oriented as to where everything was in the building (entrance, cafeteria, his clinic, his office), we looked over the notes for the first patient together. During that time, I also started looking through some of Dr. Marciscano’s recent presentations at MSK on encouraging radiation therapy and immunotherapy combinations.

We met with around seven patients that day (almost all newly diagnosed localized prostate cancer disease), including a couple of add-ons. A relatively normal number of appointments, with some just status checks and some new consultations, Dr. Marciscano described. While I will not go into any specifics due to HIPAA regulations, I’ll go over a couple of highlights/general findings that I learned as I shadowed Dr. Marciscano/sat in with him during patient meetings:

• Newly diagnosed patients were given their diagnosis based on a few tests… (*note: simplified)
  • Prostate specific antigen (PSA) blood test – measures PSA levels in the blood; because PSA is a protein made by the prostate/prostate cancers, if there is a very rapid increase in the PSA levels then this could mean there are cancer cells present in the prostate
  • Digital rectal examination (DRE) w/ the PSA test
  • Biopsy – remove tiny amounts of prostate tissue that are then reviewed by the pathologist; the pathologist will assign…
  • Gleason Score – pathologist reviews the tissue and gives a primary and secondary pattern score randing from 3-5, with 3 being malignant tissue closest to normal and 5 being high-risk/highly aggressive cancer; when these two scores are combined, the prostate cancer is assigned a Gleason grade then helps classify patients as  low risk, intermediate, or high-risk (and even further) – when used in conjunction with other clinical factors like the DRE and PSA level.
  • CT/MRI/bone scan – check if there is metastasis (if the cancer has spread) by looking at the lymph nodes and the bone; whether or not the cancer is pushing against anything/threatening to invade the nodes
  • MSK IMPACT testing (specially offered by MSK) – blood test and biopsy to see if there are any germ line mutations (passed down from family/if there is family history of breast cancer/prostate cancer etc.) and potentially use specific drugs to target these mutations
• After reviewing the results from these tests, Dr. Marciscano works with his team to develop a treatment plan (if the patient so chooses to pursue radiation and is a good candidate for this); there are a couple options at MSK (not comprehensive):
  • Radiation therapy (RT)
    • Conventional (lower doses over longer period of time), moderately hypofractionated, and stereotactic ultra-hypofractionated radiation therapy to the prostate (higher doses over shorter period of time)
    • May include combination with hormone treatment
  • Surgery
    • If there is still a rising/high level of PSA even after the cancer is removed, it is possible there are some cancer cells left; in this case, post-operative salvage RT + hormone treatment to cure the biochemical recurrence
  • Brachytherapy (can also be used alone or in conjunction as a booster dose of radiation) – radioactive sources or “seeds” are implanted into the prostate for either a short (high dose rate) period of time intraoperatively or permanently (low dose rate)
• All of these therapies have various side effects, ranging from fatigue to urination problems/incontinence to
  • Ongoing treatment – more side effects associated with RT
  • Newly diagnosed – IPSS helps track symptoms/sometimes have no symptoms at all
• Palliative RT care can also be provided to patients whose cancer is now metastatic
• Speaking another language is incredibly helpful – Dr. Marciscano could personally connect with a patient speaking Spanish and I helped Dr. Marciscano by speaking Chinese to a patient

Technicalities and specifics about prostate cancer aside, I also witnessed the emotional, financial, and physical toll a cancer diagnosis takes on patients and their families. It is incredibly difficult to adequately inform patients on the extent of their disease while also reassuring them of their treatment options and their path going forward. Finding this balance is crucial – that’s why, at MSK, radiation oncologists, like Dr. Marciscano, work together with surgeons/urologists to allow newly diagnosed patients the opportunity to consider all options before making an important decision on their treatment.

Dr. Marciscano’s team includes his nurse, Mark, who prepares patients (vitals etc.), his assistant, Tabatha, who manages his appointments, and many others at both campuses. Indeed, there is a lot of administrative work (replying to emails, paperwork, patient compliance forms for treatment, etc.). He also works with surgeons/urologists, pathologists, physicists, dosimetrists (for MRI), medical oncologists, and more to ensure that the patient is receiving the best possible care at every step.

At the end of the clinic day, I ultimately realized that one of the most important aspects of going into the medical field as a physician, and especially in oncology, is maintaining a warm physician-patient relationship. Distilling medical jargon down to information that can be shared with patients and their families is an important skill that doctors must develop and hone; Dr. Marciscano is a wonderful example: he gently eased patients into understanding their disease with layperson terms that were clear and concise, knowing when to comfort and when to caution.

While my day finished around 4:30 to catch the bus back to Jersey, Dr. Marciscano had a couple more patients left to see. After each patient, he is very organized and updates all his notes, making sure that every patient’s story is fully represented.

It was a pretty busy clinic day, but I’m happy to have learned quite a bit about prostate cancer and its available treatments.

Friday, May, 10, 2019 (pt. 2)

TL;DR: We saw around seven patients in total, ranging from those with newly diagnosed localized disease to status checks (ongoing treatment) to metastatic disease – mostly for prostate cancer. As I shadowed Dr. Marciscano and sat in on patient meetings, I was able to learn about prostate cancer and the cutting-edge treatments offered at MSK.

The day started off bright and early as I headed into the city on the 6:45 AM commuter bus with my dad, getting to New York around 7:45. From Port Authority, I took the “shuttle”/subway to Grand Central and another subway (the 6) from Grand Central to the 68th/Hunter College station uptown. After a short walk, I made it to MSK’s main campus, 1275 York Avenue, ready to start the day around 8:15.

One of the first conversations Dr. Marciscano and I had (in fact, in a call prior to clinic that day), was about his schedule. Because he holds clinic in both Monmouth and New York, he splits his days up between the two locations. In addition, rather than having a little bit of clinic every day, he arranges his schedule to see all his patients on Fridays (NY) – and occasionally Wednesdays (NY) – and Saturdays (Monmouth). He uses the other days to catch up with administrative work, treatment planning (which I’ll get into in the next post), and pursue research projects. As he explained this schedule, I started to realize that doctors do not only see patients. They may also pursue research on the side (typically through clinical trial work), whether it be lab work or retrospective studies. Most importantly, he advised, it’s all about finding where your passion lies (in the lab or in the clinic) and developing a satisfactory balance between the two. (MD life advice #1!)

Once I got oriented as to where everything was in the building (entrance, cafeteria, his clinic, his office), we looked over the notes for the first patient together. During that time, I also started looking through some of Dr. Marciscano’s recent presentations at MSK on encouraging radiation therapy and immunotherapy combinations.

We met with around seven patients that day (almost all newly diagnosed localized prostate cancer disease), including a couple of add-ons. A relatively normal number of appointments, with some just status checks and some new consultations, Dr. Marciscano described. While I will not go into any specifics due to HIPAA regulations, I’ll go over a couple of highlights/general findings that I learned as I shadowed Dr. Marciscano/sat in with him during patient meetings:

• Newly diagnosed patients were given their diagnosis based on a few tests… (*note: simplified)
  • Prostate specific antigen (PSA) blood test – measures PSA levels in the blood; because PSA is a protein made by the prostate/prostate cancers, if there is a very rapid increase in the PSA levels then this could mean there are cancer cells present in the prostate
  • Digital rectal examination (DRE) w/ the PSA test
  • Biopsy – remove tiny amounts of prostate tissue that are then reviewed by the pathologist; the pathologist will assign…
  • Gleason Score – pathologist reviews the tissue and gives a combination of scores from 1-5, with 1 being tissue closest to normal and 5 being high-risk/highly aggressive cancer; when these two scores are combined, the prostate cancer can then be classified as low risk, intermediate, or high-risk (and even further)
  • CT/MRI/bone scan – check if there is metastasis (if the cancer has spread) by looking at the lymph nodes and the bone; whether or not the cancer is pushing against anything/threatening to invade the nodes
  • MSK IMPACT testing (specially offered by MSK) – blood test and biopsy to see if there are any germ line mutations (passed down from family/if there is family history of breast cancer/prostate cancer etc.) and potentially use specific drugs to target these mutations
• After reviewing the results from these tests, Dr. Marciscano works with his team to develop a treatment plan (if the patient so chooses to pursue radiation and is a good candidate for this); there are a couple options at MSK (not comprehensive):
  • Radiation therapy (RT)
    • Conventional (lower doses over longer period of time), Stereotactic hypofractionation accelerated radiation therapy to the prostate (SHARP) (higher doses over shorter period of time)
    • May include combination with hormone treatment
  • Surgery
    • If there is still a rising/high level of PSA even after the cancer is removed, it is possible there are some cancer cells left; in this case, post-operative salvage RT + hormone treatment to cure the biochemical recurrence
  • Brachytherapy (can also be used in conjunction as a booster dose of radiation) – radioactive “seeds” are planted into the prostate for either a short (high dose) or prolonged period of time (low dose)
• All of these therapies have various side effects, ranging from fatigue to urination problems/incontinence to
  • Ongoing treatment – more side effects associated with RT
  • Newly diagnosed – IPSS helps track symptoms/sometimes have no symptoms at all
• Palliative RT care can also be provided to patients whose cancer is now metastatic
• Speaking another language is incredibly helpful – Dr. Marciscano could personally connect with a patient speaking Spanish and I helped Dr. Marciscano 🙂 by speaking Chinese to a patient undergoing treatment

Technicalities and specifics about prostate cancer aside, I also witnessed the emotional, financial, and physical toll a cancer diagnosis takes on patients and their families. It is incredibly difficult to adequately inform patients on the extent of their disease while also reassuring them of their treatment options and their path going forward. Finding this balance is crucial – that’s why, at MSK, radiation oncologists, like Dr. Marciscano, work together with surgeons and urologists to allow newly diagnosed patients the opportunity to consider all options before making an important decision on their treatment.

Dr. Marciscano’s team includes his nurse, Mark, who prepares patients (vitals etc.), his assistant, Tabatha, who manages his appointments, and many others at both campuses. Indeed, there is a lot of administrative work (replying to emails, paperwork, patient compliance forms for treatment, etc.). He also works with surgeons, urologists, pathologists, physicists, dosimetrists (for MRI), medical oncologists, and more to ensure that the patient is receiving the best possible care at every step.

At the end of the clinic day, I ultimately realized that one of the most important aspects of going into the medical field as a physician, and especially in oncology, is maintaining a warm physician-patient relationship. Distilling medical jargon down to information that can be shared with patients and their families is an important skill that doctors must develop and hone; Dr. Marciscano is a wonderful example: he gently eased patients into understanding their disease with layperson terms that were clear and concise, knowing when to comfort and when to caution.

While my day finished around 4:30 to catch the bus back to Jersey, Dr. Marciscano had a couple more patients left to see. After each patient, he is very organized and updates all his notes, making sure that every patient’s story is fully represented.

It was a pretty busy clinic day, but I’m happy to have learned quite a bit about prostate cancer and its available treatments.