Carol S. Viele RN MS OCN Clinical Nurse Specialist Hematology-Oncology-Bone Marrow Transplant UCSF Associate Clinical; Professor Department of Physiological Nursing UCSF School of Nursing

Overview Held in Boston, Massachusetts April 29-May 1, sessions over 3.5 days of the meeting Session topics included: Infection, Sepsis Update Clinical Trials/ Protocol Issues International Oncology Ethics Preparing for the future of Oncology Nursing BMT Toxicities Safe Handling Issues Genotype directed therapy Genetics

Highlights in Crash Course in BMT Presenters from Johns Hopkins, Seattle Cancer Care Alliance and Stanford University Topics: Pulmonary Issues, Hepatic Toxicity and Hepatic GVHD and Skin Toxicity Pulmonary Issues Incidence 30-60% Cause of death 60% Diagnosis Bronchoscopy Lung biopsy Risk Factors/Etiology Aspergillus CMV Pneumocystis jiroveci Bronchiolitis Obliterans BOOP DAH

Highlights in Crash Course in BMT Interventions Antibiotics Antifungals Antivirals Steroids Anxiolytics Benzodiazepines Dypsnea management

Highlights in Crash Course in BMT Hepatic Complications Sinusoidal obstruction syndrome Graft versus host disease Drug induced lung injury Infections Bacterial Fungal Viral Cholecystitis

Highlights in Crash Course in BMT Diagnostic tests Laboratory data Imaging Liver biopsy Prevention Ursodiol Antifungals Antivirals Conditioning regimens Decreased intensity regimens No cytoxan

Highlights in Crash Course in BMT Treatments Low dose tissue plasminogen activator 20% response Antithrombin III Defibrotide > 36 % response rate

Highlights in Crash Course BMT Hepatic Graft versus Host disease Onset 2-4 weeks post BMT Jaundice and increased LFT’s Staging directly related to level of bilirubin Prevention and Treatment Calcineurin inhibitors Mycophenolate mofetil Methotrexate Ursodiol Steroids ATG Sirolimus Rapamycin Monoclonal antibodies

Highlights Genotype Directed Therapy Lung Cancer By Lecia Sequist MD, MPH NSCL Cancer therapy Chemotherapy- modestly successful Molecular targeting Key pieces to understand the cell biology of each individual’s tumor Treatment effective against the particular biology of tumor EGFR dysregulation Tyrosine kinase inhibitors in lung Gefitinib- Iressa Erlotinib- Tarceva

Highlights Gene Directed Therapy Lung Cancer Treatment: Find EGFR mutations in patients 10% of lung cancer patient have EGFR mutations Response rates as high as 70% in this group of patients 1 Based on the Mok trial US is looking at need for molecular testing of tumors More common in: Women Never smokers Little smoking history Mok 2009 NEJM

Highlights Gene Directed Therapy Lung Cancer Targeted therapy eventually develops resistance Mass General is doing repeat biopsies to track resistance development in tumors Initial response is usually 12 months Looking at another pathway the MET inhibitor Adding a MET inhibitor with Erlotinib Another pathway is ALK translocation First described in 2007 Can be responsible for lung cancer progression

Highlights Gene Directed Therapy Lung Cancer Crizotinib – a new agent being trialed and the target is ALK Phase I study 150 Patients Dramatic responses ? FDA approval in 2011

Highlights Gene Directed Therapy Lung Cancer Future genotype directed therapy in lung cancer KRAS ALK BRAF MET PDGFR EGFR

Highlights Biology of Pediatric and Adult Cancers John Maris MD Children’s Hospital Philadelphia Belinda Mandrell PhD RN PNP The future in cancer treatment is a “ personal approach” Need to understand hereditary cancers Genomic profiling Practical and ethical implications

Highlights Biology of Pediatric and Adult Cancers Childhood cancers Continue to cause significant morbidity and mortality Cure rates are stagnant Late effects are significant Childhood cancers represent a microcosm of cancers in general Cancer is the leading cause of death in children except for accidents 2/3 of children who survive have life long disabilities 1/4 of the children who survive have significant life long disabilities such as CHF and hearing loss

Highlights Biology of Pediatric and Adult Cancers Molecularly targeted agents Increase the cure rates Decrease the toxicity rates

Highlights Biology of Pediatric and Adult Cancers Neuroblastoma Median age at diagnosis 17 months 15% of childhood mortality Induces significant morbidity 30% of cases spontaneously resolve 50% of cases are high risk disease Need to define the molecular targets Genetic basis of disease Define the oncogenic drivers of this disease

Highlights Biology of Pediatric and adult Cancers Genomic profiling ALK (Anaplastic lymphoma kinase) gene is the major familial neuroblastoma gene and is located on chromosome 2 Occurs in 80% of familial disease PHOX 2B occurs in 10% of Familial neuroblastoma

Highlights Biology of Pediatric and adult Cancers Genomic Profiling includes: DNA copy numbers- Single Nucleotide Polymorphism arrays RNA copy numbers – Expression arrays Mutations- Sequencing analysis Vision for all patients they will all have DNA sequencing done at diagnosis. As we treat patients mutations will occur and moving forward we can profile the DNA and RNA alterations

Highlights Biology of Pediatric and Adult Cancers Genetic Profiling Considerations Family history may suggest a genetic cancer syndrome Tests need to be adequately interpreted Consent for testing must occur Pre and Post counseling needs to occur Patients need to know the results may affect their ability to obtain life insurance not health insurance

Highlights Biology of Pediatric and Adult Cancers Informed Consent Issues: Clinical Implications Importance for children Accuracy of testing Fees Psychological issues Confidentiality issues Insurance issues