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Personalized Cancer Care Fighting Melanoma · Talking FACS

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  Welcome to Talking FACS, and thank you for tuning in to Cancer Conversations
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  on Talking FACS, a podcast collaboration between the University of Kentucky
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  Markey Cancer Center and the UK Martin-Gatton College of Agriculture,
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  Food and Environment's Cooperative Extension Service.
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  We will share with you the latest developments in cancer prevention,
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  diagnosis, treatment and research from the experts at Markey Cancer Center,
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  Kentucky's only National Cancer Institute designated Comprehensive Cancer Center.
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  Talking FACS is hosted by the UK Family and Consumer Sciences Extension Program.
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  Our educators share research knowledge with individuals, families,
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  and communities to improve quality of life.
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  Complex issues require more than one solution and more than one voice.
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  Thank you for joining Cancer Conversations on Talking FACS.
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  I am your host, Mindy McCulley, Extension Specialist for instructional support
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  with Family and Consumer Sciences Extension.
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  Today, we will explore multiple modality management and interdisciplinary collaborations in action.
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  From research to practice and from the university to the community,
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  this show highlights how combining methods and working across disciplines leads
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  to more responsive, effective treatment.
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  My guests are Dr.
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  Ayman Qasrawi and Dr. Ruta Arays, both assistant professors of medicine with
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  the UK Markey Cancer Center.
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  Dr. Qasrawi, or Dr. Q, specializes in hematology, and Dr.
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  Arays specializes in medical oncology. Welcome to you both.
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  Thank you so much. Thank you. I'm so glad that you are here to talk about something
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  that I haven't heard a lot about. And so I'm guessing it is a new concept for our listeners as well.
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  So let's just talk about what this type of treatment means for people across Kentucky.
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  I am a medical oncologist, and I mostly see skin malignancy patients,
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  the bulk of which are melanoma patients.
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  And for a very long time, we have not had a lot of great options for our melanoma
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  patients, but within the last 10 to 15 years,
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  we've been fortunate to have things like immunotherapy appear on the scene that
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  have really helped a fair bit in making outcomes for those patients a lot better,
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  even for those with fairly advanced or what we would call metastatic disease.
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  However, in those patients, sometimes the therapies are not effective or they
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  stop working at a certain point.
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  In those situations, sometimes those patients have specific mutations that we
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  could target with oral therapies that can sometimes be good,
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  but not every single person has that.
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  Only about half of the patients with melanoma have what's called a BRF mutation
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  for which we have targeted therapies. So again, those patients are kind of in
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  a tough spot if they don't have the mutation or even if those drugs stop working.
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  So once we run out of those options, so as you can tell, not that many to begin with.
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  It's a really difficult place for a patient to be. So we've been very fortunate
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  that in the last two years, about two years ago, exactly at this point.
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  Something called tumor infiltrated lymphocytes has been approved for the treatment
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  of advanced melanoma that's refractory or progressive on the therapies that I just mentioned.
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  It's a wonderful treatment, but it's kind of a big effort among many,
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  many groups, many specialists, not just medical oncologists,
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  but other specialties as well.
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  And that's kind of what we're here to talk a little bit about. And that's where Dr.
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  Q's portion is probably the bulk of what's so important about the multidisciplinary
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  approach to getting this done.
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  So Dr. Q, tell us a little bit more about this multidisciplinary approach that is targeting melanoma.
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  Yeah. So first, I'm one of the physicians with the Division of Hematogenic Cellular
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  Therapy with the University of Kentucky. So I mostly see leukemias from a procedure
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  called the bone marrow transplantation.
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  But I also foresee many of the cellular therapies for what we call solid tumors,
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  because if we classify cancer,
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  we generally classify it into solid cancers, such as organ cancers and skin
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  cancers, as well as the liquid malignancies or the liquid cancers.
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  So for my role, basically, when the product got approved, I had conversation
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  with Ruta and basically we said we need to bring the therapy for our patients in the Commonwealth,
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  especially that we didn't have many other centers in the state that offered the therapy.
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  So we went through a long process with contracting, training, and creating...
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  Guidelines for our center, and then ultimately when we got activated,
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  we have started treating patients.
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  Maybe six months ago, when we started treating the patients,
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  we have treated maybe six, seven patients so far.
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  So we had a good experience with the treatment so far.
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  And as the time passes by, there's a lot of hurdles that we passed,
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  but I think the process is getting much smoother.
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  So from my perspective, you know, what happens is Ruta identifies a patient
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  that they are a candidate for this kind of therapy.
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  And I call this treatment, you know, as kind of like a science fiction because
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  you're essentially utilizing the patient's immune system to attack the cancer cells.
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  So the product is actually alive.
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  It's live cells that we extract from the cancer cells.
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  So what happens is we identify the correct patient by looking at a lot of variables,
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  including making sure that they are, they have adequate organ function,
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  they have adequate organ, you know, and they also have adequate.
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  Psychosocial support. So we do a comprehensive evaluation.
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  And after that, we will have one of our experienced surgeons evaluate the patient.
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  And then what happens is we extract a part of the tumor.
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  We extract actually almost a golf-sized part of the tumor. So we need to have an adequent tissue.
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  The surgeons will really help us in identifying which site of disease we have to extract.
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  And after that, we send the tumor to the company that manufactured the product,
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  and then they extract that part of the, that's called the lymphocytes.
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  The lymphocytes are part of your immune system that attack the cancer cells,
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  and they normally attack infected cells, but in this situation,
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  they attack the cancer cells.
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  So this is how the treatment works, is utilizes the patient's immune cells that
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  are attacking the cancers.
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  They grow these cells in the lab, and then they ship the products back to us.
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  And after they ship, they are shipped to us, then basically they are admitted to the hospital.
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  They get a week of chemotherapy, and that chemotherapy is designed to basically
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  suppress the patient's immune system, to allow for these immune cells to grow in the patient's cells.
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  I always try to mimic it by, you know, your immune cells system is kind of a closed room.
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  There is only a very limited space of how many cells they can grow.
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  So when we deplete the patient's immune cells, then these basically infiltrating
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  lymphocyte cells or the TELT therapy product will grow in your body.
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  Then we use a very short protein called interleukin-2 to grow these cells in
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  your body. and then the patients stay in the hospital for roughly seven days
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  and then they're monitored closely outpatient once they are getting discharged.
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  The reaction to this type of treatment? Is it better than, say,
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  standard chemotherapy where you're depleting everything?
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  It sounds like to me what we're trying to do is just deplete those cancer cells, not,
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  everything that cancer patient might come across. Yeah, and melanoma is a tricky
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  thing because it doesn't really respond to chemotherapy.
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  So it's normally not a huge part of treatment.
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  That's why we talk about the immunotherapy and the other drugs,
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  because melanoma doesn't really respond to chemo.
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  And I love how Dr. Q talks about it as being almost science fiction,
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  because it's a great way of thinking about it,
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  because what we're trying to do with this kind of complicated process is sort
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  of train the patient's immune system to go after the melanoma when we think
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  the immune system was not recognizing it very well before and allowing it to
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  grow and kind of get out of control.
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  So the chemo is kind of meant to deplete everything that they have, kind of create, and Dr.
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  Q, correct me if I'm wrong, because this is definitely your arena, not mine,
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  but just create the right environment for the till that we harvested and amplified
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  to take root and grow so that the immune system kind of can become strong again against the melanoma.
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  So we're sort of rewiring your
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  patient's immune system to try to get it to fight the melanoma better.
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  Immunotherapy that we treat melanoma with does that to an extent, but not this well.
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  And these cells are coming from the patient's tumor itself.
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  So it's kind of personalized medicine in a lot of ways because it is coming
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  from them. It is not a product that's meant to fit everyone.
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  It's meant to fit their cancer.
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  So that's the other thing that makes it very unique and complicated.
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  Like Dr. Q said, there's the process of harvesting the tumor itself,
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  which requires usually at least a minor surgery, depending on the spot we're choosing.
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  Sometimes it's a lymph node. Sometimes it's a spot in the lung where the melanoma has grown.
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  But that's the part that we take out of the patient and try to go after those
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  lymphocytes, those wet blood cells that are kind of enmeshed in the tumor.
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  That theoretically when grown and strengthened should be able to fight it better
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  so it's kind of it's a very unique process.
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  That has been theoretically in the works for a very long time,
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  and it's very exciting that it's finally approved for us to use.
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  It definitely works better than conventional chemo. It works better than some
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  of the things that we try for some of these patients that stop working.
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  Taking the immunotherapy as opposed to traditional types of therapies,
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  and it sounds like to me also then it might help to fight against recurrence
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  because they've already got the antibodies in them.
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  That is exactly what I wanted to say, actually. So with all the cancers that
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  are stage four or spread, with quite limited exceptions, most of the time,
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  specific with solid cancers,
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  the chemotherapy, what it does, it can stop growing the cancer for a short period of time.
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  Then the cancer cells can outsmart the chemotherapy and start growing in other ways.
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  But most of the time, the treatment effect is for a short period of time and
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  usually measured in months.
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  Sometimes in years, but most of the time it is measured actually in months for
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  most of the cancers, especially like aggressive cancers like melanoma.
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  And as Ruta mentioned, the traditional immunotherapy, the responses are good,
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  but not good in everyone and limited in some of the patients, as I mentioned.
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  So the advantage when you actually train the immune system by giving live cells
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  or live cells is the responses can last for a long period of time.
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  And it is exactly what you mentioned.
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  It's like having an infection in the past, right? And then you are immune for
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  the rest of your life, right?
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  So we're not there yet to the degree that people are immune for the rest of
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  their life, but I think it's improving with time.
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  The responses are not for everyone, but people who respond, they can have a
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  maintained response for years. That's at least what we know.
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  So in an era where patients fail immunotherapy, and then the chemotherapy works
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  in maybe not more than one out of 10 patients, and if it works for a short period
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  of time, and they're very toxic too.
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  So this is a remarkable achievement that you can actually have patients who
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  survive 40 years and historically speaking, they didn't have any options at that time.
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  Is it possible that in the future we will have, you know, a vaccination if your
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  family has a history of, say, of some type of cancer and then you can test for
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  that and then get vaccinated against it?
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  There's actually some studies in that right now.
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  There's a melanoma vaccine study actually combining it with immunotherapy.
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  I believe there's other vaccines in the works as well. So it's not too far-fetched
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  that maybe someday something like that would be possible.
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  Right now, I think we're kind of far from that specificity, being able to kind
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  of pinpoint something that you have a family history of or something like that.
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  But someday it might be because we're already working on those things as cancer treatments now.
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  That's exciting. It is.
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  I want to mention also like people, let's say, are being treated at another
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  institution in the Commonwealth.
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  And they read and they want to hear about me. I think it's very important that
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  the referral to us, or Dr.
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  Ruta and myself, is as quickly as possible whenever we think that the patients
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  are not responding well to immunotherapy.
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  You know, we're learning with time, obviously, and this is a fairly new program, as I mentioned.
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  But what at least Ruta and I have learned so far is the patients who have little
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  amount of disease, if you know what I mean, is if you think about it the same
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  way with an infection, right?
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  If you have a massive infection, then you need to intervene with antibiotics
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  as quickly as possible for your immune system to function better.
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  But if you have a little bit of an infection, then you might not need the antibiotics
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  and your immune system can't take over very easily.
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  So it's kind of exactly the same way. So if you have a lot of cancer cells,
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  a lot of the time the immune cells might not have time to learn how to attack
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  those cancer cells. So I think it is very important that these patients are
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  referred and evaluated properly.
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  In a timely manner. Absolutely agree with that.
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  Melanoma can get out of control very quickly, as Dr. Qand I have both found.
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  So as soon as progression is seen with a melanoma patient who has advanced disease,
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  they should really start strongly considering this option and being referred
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  to a center who can offer them TILs.
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  And you mentioned that this is available at UK and at UofL, correct?
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  Correct. In Kentucky, yes.
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  Of course, we talk about screenings and that sort of thing. Is there a screening
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  where somebody might be referred after that screening for?
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  Automatically, or would it be something that they're referred after meeting
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  with their other oncologist?
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  Usually probably after meeting with their other oncologist, but it's mainly just monitoring.
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  We always monitor disease that's advanced with scans, so either CT scans or
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  PET scans, and at the first sign that the current therapy really isn't working,
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  meaning there's growth through the treatment, they should probably be referred.
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  Our guidelines suggest as soon as possible.
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  Sometimes there's even testing done in the blood to see if you can find a little
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  bit of those cancer cells already starting to come up.
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  And some institutions are even referring when you're not even seeing the progression
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  on the scans, but when you're seeing the cancer cells in the blood a little
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  bit, just because, again, there's no such thing as too soon.
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  In some of these situations, you really want to start the process in a timely
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  fashion, even if at the time that they see us, they might not have a perfect
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  site to go after for procurement.
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  At least we can get a lot of the things we need to get done kind of out of the way because Dr.
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  Q kind of alluded to the fact that it's a pretty intensive chemotherapy.
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  Usually patients need to have pretty much perfect organ function.
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  So there's a lot of testing that needs to be done to make sure that they're
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  good candidates for this process and me identifying it as part of it.
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  But, you know, patients actually meeting the criteria to get the treatment is
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  definitely a big part of it too.
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  And I would guess that there probably is a point where it's too far gone. Is that right?
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  Unfortunately, yes. We've had a couple of those situations too where the burden
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  of disease was just too massive to really make any difference with any of the
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  treatments we had to offer.
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  And again, melanoma, sadly, is something that can become aggressive and grow
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  quickly, which is again why we're both emphasizing the time frame so much.
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  Yeah, I want to emphasize, as Ruta mentioned, she said, you know,
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  there is no early referral.
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  Definitely, there is not super early referral, but there is a super late referral, unfortunately.
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  And I want to mention, unfortunately, we had a couple of cases where the melanoma
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  grew on us while we're waiting for the product to be manufactured.
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  So that whole process can take five to seven weeks and sometimes longer.
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  So during that time, the melanoma is going to continue to grow.
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  And if it's one of those aggressive diseases, then if you already failed in
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  therapy, then you don't have much options to control the disease while you are
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  awaiting the product to be manufactured.
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  That's why the most important is the critical timing of the referral for us.
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  I am I'm just sitting here with my mouth open thinking about all the things
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  that can happen and how this can make a real difference in the lives of those
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  who have been diagnosed with an aggressive form of cancer that maybe there wasn't a treatment for,
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  previously so I thank you both for your time and I thank you for your expertise
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  and your willingness to keep looking for those things that are going to make
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  a difference in the lives of cancer patients,
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  absolutely If you're just tuning in, you're listening to Cancer Conversations
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