Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
Andrew Schorr:
Yeah. I’ve got it. Sorry.
Dr. Gray:
Yeah? Sorry.
Andrew Schorr:
Dr. Rosenberg, related to toxicity you referred earlier about MRI-guided radiation. What are you doing in the radiation oncology field to get at the cancer, but not effect either healthy tissue – and also lower the side effects that can go with radiation. People that fatigue and other things that go along with it. And all of you have been talking about higher quality of life where you might be living with lung cancer.
Dr. Rosenberg:
Yes. Yeah. It’s a great question. And I think how we’ve approached this in radiation oncology is actually by shortening our treatment courses. And as our technology has improved it will also give us very small volumes of irradiation with high doses to destroy cancer cells, but also sparing normal tissues. And as patients are living longer with lung cancer, we kinda have to say sometimes they’re responding well to chemotherapy or immunotherapy or targeted therapy, but one area is starting to grow, we use this targeted therapy called stereotactic body radiotherapy, SBRT. So, [inaudible] go after these important small areas that might be not responding appropriately or may even be resistant.
But these are targeted areas that we’re irradiating that are very small in volume. That’s really helped us limit toxicity, but to normal tissues going forward. And with the new MRI-guided treatment program, which is where my focus is gonna be, is that by having the MRI help us guide our treatment in real time, we can make our volumes even smaller. And by shrinking our volumes and targeting tumors more appropriately we can hopefully spare normal tissues and actually decrease side effects long-term for patients.
And so, again working with our medical oncology colleagues is that if there’s an area of resistance that pops up, an area that we can very precisely target, we’re still sparing a lot of the normal tissues in your body.
Andrew Schorr:
Okay. Precision radiation oncology?
Dr. Gray:
Yeah. Yes.
Andrew Schorr:
Okay.
Dr. Gray:
And we do that also. And if I may add that if there’s somebody who’s on a treatment benefiting and they just have one area that’s kinda this rogue tumor that breaks through and becomes resistant, that definitely looping in the radiation oncologist, working with Dr. Rosenberg and his team, and targeting that specific area can be very effective for patients.
Andrew Schorr:
Okay.
Dr. Gray:
Before you switch therapy.
Andrew Schorr:
Here’s another aspect of immunotherapy. So, we talked about these PD1, PD-L1 drugs, checkpoint inhibitors. So, another area that’s particularly happening in the leukemia’s that I know well is what’s known as CAR t-cell therapy, chimeric antigen receptor t-cell therapy. Where if I get it right, correct me if I’m wrong, you can sort of engineer t-cells to become sort of a targeted therapy.
Dr. Gray:
Yes.
Andrew Schorr:
All right. So, what about this in lung cancer, Dr. Gray?
Dr. Gray:
Yeah. So, it’s a great question. So, one of the areas – this has really taken off in the hematologic malignancies are these CAR-T therapies. The hematologic malignancies are very well-defined by specific markers on the cells that are uniformly found across different types. So, lymphomas, leukemias. In the solid tumor realm, it’s been a little bit more of a challenge with finding where to specifically target. And also, to target the cells without adding significant toxicity to the patients.
So, we do have what’s called an ICE-T therapy here. It’s the immune and cellular therapy. It has medical oncologists on that team, both hematologists and hematologists. And they’re working together to help bring what we’ve learned from the hematology world over to the solid tumor realm. So, it’s new. I don’t think it’s yet ready for FDA-approval, but absolutely a very exciting, exciting field. Again, the purpose of these is to create these long-lasting responses with a personalized medicine approach.
Andrew Schorr:
Yeah. I wanna thank Gordon for that question. I think we hear about – you mentioned TV commercials, or we see an article in the paper.
Dr. Gray:
Yeah. Great question.
Andrew Schorr:
And we say, “Oh, how does that apply to me?” Or, “Should we get on a plane and go somewhere because they’re trying this out?” It’s really tough. So, Dr. Boyle, you see this changing field.
Dr. Boyle:
Okay.
Andrew Schorr:
What would you say knowing what you know in going on and identifying new genes, if you had a family member – and I hope you haven’t, but if you had a family member diagnosed with one of these conditions, what advice would you give them? Because you’re on the inside. Or maybe you have friends or neighbors that call you up, “Oh, my God. We got this diagnosis. What should we do?” What’s sort of an operating system for patients and families today? What would you say?
Dr. Boyle:
Right. Well, one thing I want to ask always, what Jhanelle was talking about earlier with the clinical trials, if you are getting the optimal standard of care plus whatever new innovative potential therapy might be available with those trials. And there actually is a better outcome with the participation in the clinical trials. They’re very carefully designed.
So, I would want a family member or a patient, it is the same, to get as much information as possible. And like Jhanelle said, it’s fine to get your care locally, but to get a second opinion at the most advanced center available to you for a second opinion. Get more information. See what’s available. Consider clinical trials. Sometimes just following the basics. Like if you have an EGFR mutation to get an EGFR inhibitor therapy and not be wanting say immunotherapy just because it’s the newest thing. That’s what I’d be thinking about. And getting the rapid care can be important too.
One thing I wanted to add onto what Jhanelle said earlier about the T-CAR conversation is that we also have a trial here with the tumor infiltrating lymphocyte. It’s not by definition a T-CAR trial, but it’s in lung cancer. And they’re basically taking lymphocytes out of tissue and growing them up in cell culture and reinfusing them into lung cancer patients in the hopes that the reinfused cells will attack the tumor. And I just think this is amazing progress that this being tried in lung cancer too.
Andrew Schorr:
Here’s a point I wanted to make. So, I hope what all our viewers get – and I think we have some pretty savvy questions that have come in. The field is changing. And so, Dr. Gray, I’m sure when you went through your training there wasn’t always a lot to talk about with patients, right?
Dr. Gray:
Oh. No. That’s very true.
Andrew Schorr:
And now we have people like Ed who are living longer, living pretty well. There are side effects we’ve talked about. Ed was talking about trying to limit that. So, the quality of life goes along with living well and living longer. But there’s a lot of progress being made, and you and your family have to be plugged into that. And yet, Dr. Boyle just referred to that. Don’t get excited about something just that you see on TV because it may not be right for your specific situation. And Dr. Gray was warning about that too. If you have EGFR, that’s not the time for immunotherapy, right?
Dr. Gray:
Correct.
Andrew Schorr:
Even though you saw the ad of people in town square. New hope for lung cancer.
Dr. Boyle:
On the highway. Yeah.
Dr. Gray:
Yes.
Andrew Schorr:
Yeah. So, you really have to – you really have to think about that. So, testing, broader panel, second opinion, team approach?
Dr. Gray:
Yes.
Andrew Schorr:
We’ve got a wonderful team here.
Here’s a question that we got in. We just have time for a few more questions. But Helen asked this question, “Is there any research or anecdotal information on how much the drug Alimta adds to the efficacy of another immunotherapy Keytruda. Does it continue to be effective indefinitely or does it only work for a while?” Dr. Gray?
Dr. Gray:
Yeah. So, there’s a recent study called the Keynote-189 study that combined pemetrexed, carboplatin, plus pembrolizumab. So, pembrolizumab is the immunotherapy. The Pemetrexed is the chemotherapeutic agent. And they treated those patients with the pembrolizumab up to about two years.
The study was published, and it was found to be positive in the sense that it improved patient’s overall survival. So, how long were you gonna live? And also, what we consider your progression for your survival. How long did it take your cancer to actually progress to the point that we would need to switch your therapy? So, it was longer in that group than just giving the chemotherapy group.
You ask a very good question. These are the questions that we also, within the lung cancer field, are asking. How long do we really need to give these therapies for? Especially when you’re giving them in combination with immunotherapy when the goals of immunotherapy are to create long-term memory.
We have studies looking at giving immunotherapy for one year. We have studies continuing the immunotherapy indefinitely. And we have studies looking at giving the immunotherapy for two years. I think outside of the stage three – in the stage three setting, the clear data is that you give it for one year. Outside of that, I still think that it’s still a tossup. My suspicion is that you should at least probably go beyond one year if you can and see if you can’t get to the two-year mark. That’s where most of the data is at a minimum.
I actually have a patient now coming up on her two-year mark in February of this year on pembrolizumab and I’ve started having those discussions with her and it’s an open discussion that, “This is what the data shows. What do you feel comfortable with?” And so, I think there needs to be a shared decision-making process within this realm also. And what the patient feels comfortable with and what the data helps to support. So, I think keep having those conversations, especially if you’re getting it combined with the immunotherapy. And hopefully there will be more to come definitively.
Just for a historical perspective, if you look back many decades ago when chemotherapy first came out, we used to give chemotherapy for a year. Then they did the trials where they actually looked at it at a year versus six months. The outcomes were the same with giving it over six months. And then they went from about six months versus about three months of therapy. And now went back a little bit, but added the maintenance in. And so, there’s definitely these trials will come, it’s just going to take time. The world of immunotherapy is very novel within the realm of lung cancer. And so, we have lots of growth to do.
But fantastic question. That’s probably one of the things that we sit and debate at our meetings very frequently.
Andrew Schorr:
So, as we come near the end of our program, I wanted to get some final comments from our panelists. I’m gonna end with Ed because Ed, I want you to talk to other patients and family members.
But what I get from this is the field is pretty rapidly changing. Whether it’s in radiation and how that applies to other therapies. Whether it’s combination therapies, sequential therapies, duration of therapies we were just talking about with Dr. Boyle. It’s about identifying new genes or combinations of genes and trying to figure that out. So, what do you wanna say to a patient audience?
I’m gonna start with you, Dr. Rosenberg. So again, we have people all around the world and they or a family member has been given what’s a pretty terrifying diagnosis.
Dr. Rosenberg:
And it’s a scary time as they’re facing this. And actually, what I’m talking about here in Madison is actually putting together your medical and emotional teams as you’re basically facing this new diagnosis. And I think that’s the big thing is putting together a team and being someplace where you have the support and you feel comfortable. And also seeking out multiple experts to try to come up with the best plan you can moving forward.
And I think as Dr. Boyle, Dr. Gray, as the panels all alluded to, seeking that second opinion just to at least know what all your options are and are available to you is really important. Building your treatment team which includes so many different experts both that you’re gonna meet in person and behind the scenes. And I think that’s the real key aspect to this.
Andrew Schorr:
Well, thank you for what you do. And this cool area you were talking about having radiation trigger a response in the cell that can make it more responsive to new medicines is really great. Good luck with all of that. Thank you.
Dr. Boyle, so you are a CSI detective. You are. You have like a magnifying glass.
Dr. Boyle:
I love my job.
Andrew Schorr:
Yeah. You have much more powerful tools than that. But you’re a sleuth. So, are you confident that this field is – will continue to expand to really unlock these secrets so you can say to these other team members, “Hey, I think this is what we’re dealing with and here’s a key pressure point to go beat that cancer.”
Dr. Boyle:
Yes. Yes. I’m very optimistic. When we validated this 170 gene panel we did not even know if we would be reimbursed, but we did it anyway because we have so much optimism that it will have value and show value. And I really feel like understanding the cancer better. And it’s a key to better therapy. And my thinking is that patients should hold onto their hope throughout their whole experience and stand their ground.
Andrew Schorr:
Yes.
Dr. Boyle:
Know what they want and don’t want and ask questions to their oncologist if they have questions. Because there’s a whole new world here and we’re all trying to figure it out together as a team. But we really appreciate the input from the patients as well. I think that’s helpful to helping all patients and future patients as well.
Andrew Schorr:
Well, I wanna thank you for what you do behind the scenes as far as we patients and family members see you. But with your colleagues around the world continue to make these discoveries so that the therapies can be targeted or more broad. But whatever they are, know what we’re dealing with, so we get what’s right for you. Dr. Boyle, thank you for being with us too.
Dr. Gray. So, you have these partners here and we have patients and family members who you’re partners to. And as I alluded to earlier, in your own career you’ve seen a lot of change.
Dr. Gray:
Yes.
Andrew Schorr:
Is this a message of hope? And are you comfortable that more of us – even now we’re talking about small cell lung cancer where there’s progress being made that can extend life.
Dr. Gray:
I’m very hopeful. I think that we have completely revolutionized how we treat patients – treat lung cancer and treat the patients battling lung cancer. We’re with you there right along helping you with that fight. And to your point, when I first started doing this I literally spoke to patients about chemotherapy. That’s what I had to offer. And it was just trying to make that selection process about which chemotherapy I thought was going to be right for you. And helping you with sequencing. “Okay, we’re gonna start with this and then we’re gonna plan for this and we’re gonna plan for that.”
And the game has completely changed, I think, with the genomic profiling. It is extremely important. We really have to go to these broad-based panels up front. And for right now, I just wanna emphasize tissue is the gold standard, but I really think that circulating tumor DNA is something that we can – certainly we’ve made a lot of significant progress and then can identify these mutations.
As you identify these mutations, checking them longitudinally over time to see how they evolve is gonna be very important. And that will help us continue to personalize treatment at what point do you pivot from a targeted therapy to a clinical trial to an immunotherapy to a chemotherapy. And all of these things come from sitting down, looking at the scans, looking at the patient, looking at these molecular reports, getting everybody on the same page and then making – again I think having a shared decision model. Setting, “What are your goals? What are your hopes?” And then making sure that we match that as best as we can.
Andrew Schorr:
Wow. Get tested, folks.
Dr. Gray:
Yes.
Andrew Schorr:
Have your family member get tested and then raise the question with your team, “Do we needed to be tested again?”
Dr. Gray:
Yes. Yeah.
Andrew Schorr:
All right.
Dr. Gray:
Absolutely.
Andrew Schorr:
And then I think Dr. Gray, I just wanna underscore a point she made about your goals.
Dr. Gray:
Yes.
Andrew Schorr:
So, Ed thinks about that. And Ed, I’m gonna give the final comments to you about speaking up for yourself.
Dr. Gray:
Yes.
Andrew Schorr:
How do you get the care that’s right for you and how do you wanna live your life? I mean you and Donna wanna do some more travelling, right, Ed? I hope you can.
Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.
