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Exploring New Frontiers in Blood Cancer Treatment · 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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and communities to improve quality of life.
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Hello and welcome to Cancer Conversations on Talking FACS.
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This partnership presentation between the University of Kentucky Markey Cancer
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Center and Family and Consumer Sciences Extension brings you the latest cancer
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research news that you can use to improve your quality of life.
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I'm your host, Mindy McCulley, Extension Specialist for Instructional Support
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with Family and Consumer Sciences Extension.
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I am pleased to have with me today Dr.
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Gregory Monohan, who is a
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professor of medicine in the Division of Hematology and Marrow Transplant.
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And we're going to talk about advances in blood cancer. So welcome, Dr. Monohan.
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Hello, thank you. This is going to be an informative conversation for me as
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well as I hope it will be for our listeners.
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But before we get started, let's just talk about, generally,
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when we're talking about blood cancers, what are the cancers that we're seeing
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that people might understand if they hear someone say it?
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Yeah, so in general, when anyone thinks of a blood cancer,
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then probably the three different broad categories that people might think of,
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number one would be leukemias, number two would be lymphomas,
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and number three would be multiple myeloma.
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And related diseases. So, those may be the three broad categories,
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but quite honestly, when a outside referring physician contacts us with a patient,
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for example, with a diagnosis of lymphoma.
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I have to cringe a little bit because part of the most recent World Health Organization
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classification, there's approximately 90 different types of lymphomas.
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Okay. Likewise, there's approximately 30 different types of leukemias.
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So when we talk about blood cancers, it's not just one simple diagnosis.
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They're very complicated, and we keep expanding the subtypes of the different
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blood cancers because we keep learning more and more information about these blood cancers.
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Well, and that is just a credit to the universities that are doing the research, right?
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Because the more we know, the smarter we get about all of these. Absolutely.
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I make the comment all the time to patients.
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I joined faculty at the University of Kentucky in
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2006 and wouldn't it be
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a tragedy if we were still treating patients all the
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same way that we were doing in 2006 you know
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that we had made no progress in the
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treatment of cancers or in particular blood cancers so the fact that we have
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a variety of different subtypes of these cancers is because there's now certain
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targeted type therapies for certain subtypes of these different blood cancers
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which has certainly improve the outcomes of the patients who have those particular subtypes.
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So do we see certain types of cancers in certain people or, you know,
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like I always thought that leukemia was a disease for, of children.
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And is that, is that right? Or is that just something that, that I've heard?
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Well, so the answer is, you know, again, of course, complex because there's
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so many different types of blood cancers. But in general, yes,
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there are some certain populations that are more prone to certain types of blood cancers.
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It's easy to think about leukemia with children because acute lymphoblastic
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leukemia is the most common blood cancer, or I should say the most common cancer
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for children in the pediatric population.
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We do see acute lymphoblastic leukemia in adults, but it's not near as common.
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And combined, all the blood cancers make up approximately, well,
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maybe one-fifth or less of all the cancers that afflict adult patient population. Okay.
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Understanding that there are so many different types of blood cancers,
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are there certain risk factors that cause people to contract these types of diseases?
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Or is it just something that's just a roll of the dice?
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Now, you know, many times when patients are diagnosed with a blood cancer,
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it's not because they were exposed to anything or that they did anything wrong.
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It can be, like you suggest, a roll of the dice. Now, we do know that certain
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features can lead to increased risk of developing blood cancers.
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You know, the most obvious thing that comes to mind is something like radiation
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exposure or perhaps if the patient had prior chemotherapy treatment for a different cancer.
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So let's say a woman with breast cancer who received chemotherapy for her breast
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cancer unfortunately may in the future develop a different type of blood cancer like a leukemia.
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So that's a treatment associated blood cancers.
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And there are certain inherited conditions that might increase the risk of a
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patient developing a type of blood cancer.
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Trisomy 21, for example, increases the risk of a patient developing a leukemia in the future.
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So it doesn't mean that everyone who had breast cancer, who got chemotherapy,
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or everyone who was born with a certain gene mutation is going to develop a
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blood cancer in the future. They just happen to have a higher risk than the general population.
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So when you see a patient for the first time, is it usually because they are
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referred by a general physician or is it because they have had other conditions
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that have brought them to you?
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Well, let's take the leukemia group first.
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So, in general, when a patient in the state of Kentucky is diagnosed with leukemia,
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then they're going to be referred to one of the two academic centers,
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either the University of Kentucky or the University of Louisville.
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They're going to be referred to a leukemia center because in the treatment of these blood cancers,
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it involves a team approach of not just the clinicians, but also a dedicated
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blood bank, a dedicated leukemia service.
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Pharmacy staffing, nursing staffing, individuals that are trained specifically
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on how to treat the leukemia and the toxicity associated with the therapy and the treatment.
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So, in direct answer to your question, it often means that patients are maybe
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suspected of having leukemia when they go to the emergency room or when they're
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seeing their primary care physician,
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and then they would contact the leukemia center and say, I think I have a patient with leukemia.
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Or they're being evaluated by one of the community oncologists who makes the
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diagnosis of leukemia and then refers them to the academic center for further
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evaluation and diagnosis management of the patient's leukemia.
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Lymphoma similarly, but again, there's so many different types of lymphomas.
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There's many lymphomas that our community oncologists are more than able to
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manage and treat those patients locally with typically systemic chemotherapy options.
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So, it's really just those patients that have very aggressive courses or that
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are not responding to initial treatments that might be referred to the academic
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center with aggressive or refractory lymphoma. And then,
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Multimaloma patients are often referred to the academic center for consideration
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of a bone marrow transplantation as part of the treatment for those patients.
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So, I guess, in general, patients typically have the diagnosis made when they're sent to us.
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Often, it may be just a preliminary diagnosis of leukemia, and then it's up
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to us to identify which subtype of leukemia they have.
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I know from recording other podcasts about other types of cancers,
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for example, lung cancer, you know, you might develop a cough or something.
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And is there some symptom that people might have with blood cancers that would
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make them suspect that they need to go talk to their primary care physician about their concerns?
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Yeah, typically if someone has a blood cancer, then we tend to think of the
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symptoms that aren't very specific, but in general,
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if you're not producing the normal amount of red blood cells,
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you're going to feel anemic, which is basically really fatigued and tired,
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which again is not a very specific complaint.
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But if you have some degree of fatigue or tiredness, especially if it's beyond
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what maybe your normal activity level,
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then when you seek your evaluation from your primary care physician or the emergency
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room or wherever you go and you complain about being fatigued or tired,
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they're typically going to check your blood counts to make sure you're not anemic.
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So anemia or symptoms of anemia would be one of the ways that if not the majority
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of our patients present symptoms.
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With a blood cancer. Other things are that if you're producing cancerous white
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blood cells, then you may not have normal white blood cells and often patients
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are going to be afflicted with various types of infections.
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So again, someone might go to the urgent treatment center or to their primary
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care doctor with complaints of fevers or an infection and fatigue and then again
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they get the blood counts checked and they discover some abnormalities in the
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blood counts that are concerning for a blood cancer.
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And the last main symptom perhaps would be if a patient has a low platelet count,
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which is often a consequence of blood cancers, then they have increased risk of bleeding.
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So people may present with either active nosebleeds or they could have skin
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changes from small hemorrhages within the skin.
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We call them petechiae, which are little dots typically on the lower extremities
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that may develop, which could be a sign of a low palate count.
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Now, lymphomas can take it a step further because those would be often cancers
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that involve lymph nodes.
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And so, patients might present with enlargement of the knots in their neck or
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in their armpits that they can feel that could be a sign of lymphoma.
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We always talk about night sweats, which is a symptom that's also hard to quantify,
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because everyone can have vivid dreams at any point and may feel a little sweaty at night.
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But what we often refer to would be as patients that drench their pillowcase
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or their pajamas, you know, three or four nights out of a given week and to
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the point where they have to actually get up and change their pajamas because they're saturated.
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So really, really extensive sweating.
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And then unexplained fevers. Again, if you don't have an active infection,
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but you're spiking temperatures 102 degrees Fahrenheit or 101 degrees Fahrenheit
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without any explanation that would be one potential sign of a blood cancer and
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then the last thing that I would throw in there would be unexplained weight loss.
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Which can be attributed to a variety of different types of cancers,
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not just blood cancers, but in particular, if a patient loses 10% of their body mass,
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so if a patient weighs 200 pounds, if they lose 20 pounds or so within a period
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of six months and they're not trying to lose weight, then that might be a sign
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that they have a potential cancer.
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So, and then, you know, again, quite honestly, we have many times patients who
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have no symptoms whatsoever, but they happen to go to their primary care doctor
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or they have an insurance physical where they get laboratory tests that are obtained,
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which shows some abnormality on the blood test, which leads to the diagnosis.
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So, it's kind of hard to identify, you know, any general specific symptom because,
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again, we're talking about literally hundreds of different types of cancers
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when we talk about blood cancers.
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Yes, I can imagine that that's true. And sometimes it's just like putting the
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pieces of the puzzle together, I would imagine. That's right. Yeah.
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Dr. Monahan, what are some of the advances in treatments that we're seeing for blood cancers?
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Yeah, so the newer treatments, you know, in talking about blood cancers,
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I think it's one of the areas in the foremost where we're using a lot of immunologic treatments now.
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So, the antiquated dogma of thinking about cancer and chemotherapy treatment and, you know,
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the undesirable side effects of losing your hair and, you know,
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being detained in the hospital for weeks at a time, you know,
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those sort of things are starting to transition.
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Again as we've learned more and more about
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the different types of blood cancers and we've
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identified different targets whether it's a gene or a molecular mutation or
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a protein you know again areas on the cancer that we can focus our attention
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that's really expanded the number of immunologic therapies and immunologic therapy treatments.
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It's not necessarily specific to just blood cancers, but again,
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we see so many options now.
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So if you have a type of lymphoma, let's say type A lymphoma,
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well, there might be two or three different treatment options for that patient
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that involve therapies that are extremely effective and not near as toxic as
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the older therapies used to be.
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And then that would be different than the lymphoma type B patient,
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let's say, where we have different treatment options, again,
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that are immunologic agents, but they're not the same ones for the lymphoma type A.
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And so just in broad categories, you know, thinking about the immunologic treatments,
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one of those treatment options is something called CAR-T therapy.
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And T stands for T lymphocytes, which is the patient's own white blood cells.
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And the easiest way to think about CAR-T therapy is this is where the patient's
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T lymphocytes are collected and then they're sent to a manufacturer where they
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are manipulated to attack the patient's cancer.
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So, they're activating the T lymphocytes, the patient's own T lymphocytes,
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to become cancer-fighting cells.
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And that may take three or four weeks to manufacture those cells,
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but then when the cells are manufactured, they're infused back into the patient
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so that the patient's own T lymphocytes, they've just been activated now.
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And they're very successful at going in and killing the cancer cells.
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So, that's an example of immune therapy that we use now for,
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well, leukemias, lymphomas, and myelomas, and that's called CAR-T treatment.
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And then there's another immunologic type of an approach, which is what we call
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the bispecific antibodies, and now in some cases, trispecific antibodies, where these are, again,
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antibodies trying to, again, to capitalize upon the patient's own immune system
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and fighting off the cancer.
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So, the antibodies will bring the patient's healthy cancer-fighting white blood
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cells in close proximity of the cancer cells. That's what the purpose of these antibodies are.
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And by doing so, that helps to activate those white blood cells to help kill the cancer cells.
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The last area I would mention would be in the TIL therapy, which is tumor infiltrating lymphocytes.
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Again, another method of trying to maximize the patient's immune system.
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This currently is being, so these treatments are actually FDA approved for some
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of the melanoma patients or for synovial sarcoma patients.
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But we're using them in clinical trials or we're pursuing clinical trials for
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lung cancer, for example.
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But with blood cancers, it's easy for us to collect the white blood cells and
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have them go around killing the blood cancers.
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It's a little bit more difficult when you're talking about tumor masses from
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cancers like solid tumors, let's say like a lung cancer or a melanoma.
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And there are already some white blood cells that are trying to kill the cancer cells.
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And so if you take tissue, specifically cancer tissue from a patient who has,
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let's say, melanoma, and they dissect down inside the melanoma,
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they can identify some of those white blood cells.
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And so what they do is they expand and grow those white blood cells in a manufacturer
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plant because they know that those are white blood cells that have the ability
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to infiltrate into the cancer space to try to kill the cancer cells.
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And so, again, in some of these solid tumors where chemotherapy may have difficulty
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penetrating in and bispecific antibodies might have difficulty penetrating in those tumors,
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using the patient's existing white blood cells, manufacturing or expanding them
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into a population of cancer-killing white blood cells and then reinfusing them
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back into the patient, we see a lot more effective killing of the cancer cells.
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So, again, dramatic responses in patients who have widespread melanoma,
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for example. So I think all three of those areas, again, I can incorporate that
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into like immunotherapy type approaches.
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So it's kind of steering away again from the whole idea of chemotherapy and
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again, instead now utilizing the patient's immune system to help really fight off the cancer cells.
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Well, it makes sense to me as someone who knows nothing about this type of treatment,
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though, but it would seem that using their own immune system would mean that
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there would be less resistance to treatment.
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Yeah. You know, again, how many times you asked yourself?
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Why is it that you know so many patients or people that smoke their whole lives
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and, you know, seem to do every conceivable thing that might suggest they should
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have gotten cancer, yet they don't get cancer? But they don't.
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Somebody who never smoked a cigarette in their life who unfortunately develops lung cancer.
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And a lot of it has to do with that individual's innate immune system and its
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effective ability to fight off any cancer cells that develop.
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Right. And so that's what we're trying to, again, capitalize upon is that immunity.
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Get the effective immune cells that help to fight off cancer involved in the fight to patients.
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Dr. Monohan, this has been a very enlightening discussion for me,
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and I'm sure that it has been for our listeners as well.
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Well, I appreciate your having me on the show. Thank you very much, and have a great day.
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