How Immunotherapy Cues Your Body to Fight Cancer

Leslie Lane: Welcome to Premier Health Now On Air. Today, lung cancer is the world's number one cancer killer, claiming more than one and half million lives every year. But now victims of lung cancer have a new reason to hope for much better odds. Doctors are using patients own healing systems to dramatically increase survival rates. The treatment is known as immunotherapy and we are fortunate to be talking with an authority on this new frontier and what it means for you and your loved ones. We're glad you're along. I'm your moderator, Leslie Lane and with me is today from Dayton Physicians is medical oncologist Dr. Tarek Sabagh who specialists in the treatment of cancer and blood diseases. Welcome.

Dr. Sabagh: Thank you for having me.

Leslie Lane: Can you help us understand what immunotherapy is and how it works?

Dr. Sabagh: Well immunotherapy is treatment using your own immune system. And it's not something new. It had been there in the works for many years. There is a lot of breakthrough coming out that we can use in our offices and community practices. So it's the refinement of the concept and using new drugs and indications that was not there before.

Leslie Lane: So we have breakthroughs but how fundamentally does immunotherapy work?

Dr. Sabagh: The treatment of cancer had traditionally being chemotherapy. The principle for using chemotherapy is cancer cells are rapidly growing cells. So if you give treatment that kills cells, you're going to kill more of the faster growing cancer cells than the normal cells. And with that came side effects. So that's how it had been used all along.

Then another question comes. So why would the cancer cell comes to start with, and comparing that to virus infection? So we get viral infection, immune system recognize it and we were over the viral infection in a few weeks or days. So how come the cancer cell keeps growing and not get detected? From asking this simple question, started the research in different ways to treat cancer by reviving the immune system to recognize that cancer cell as a foreign and not as a self and attack it.

Leslie Lane: So somehow the cancer cell was able to hide or disgust itself?

Dr. Sabagh: Evade.

Leslie Lane: Evade.

Dr. Sabagh: Evade the immune system and that's just one of the difficulties in immune therapy for cancer cells. You know when the human body has a viral infection, the virus is completely foreign to the body, so it easily can be recognized. But when you have a cancer cell that started as a normal cell, so there are still some similarities to the self. And that what can ... makes it hard. They make the cancer cells able for sometime to evade the immune system. Not from the get go, its foreign cell but there are some similarities to the normal cell.

Leslie Lane: So you mentioned that there have been some big breakthroughs in this kind of treatment that you've been studying for a while. So what's exciting?

Dr. Sabagh: A lot. The principle off immunotherapy, the breakthrough recently is the fact it's available in community practices. It used to be there before we have to send patients to the NIH for clinical trial or something like that or somewhere across the country but the refining that treatments to the point you can get this close to home, I think that's the fruits of many years of research that's now we're seeing in our community.

So for example, one kind of lung cancer is called the small cell lung cancer. Well, small cell lung cancer, it's very aggressive kind of cancer and had always been used with chemotherapy. And so I finished my training in cancer in 1997 between '95 and '97 and when I did my training we were using chemotherapy before this kind of cancer, which we are still using now. And my mentors told me that the same chemotherapies are used for this kind of cancer.

Well, I think was last week or two weeks ago, and immunotherapy was approved for this kind of cancer. So you can do the math and see this is really a breakthrough in some kinds of cancers we didn't have good treatments for in the past.

Leslie Lane: I understand there was a study earlier this year that produced some very dramatic results and difference in survival rates from the prior standard of care, can you talk about that?

Dr. Sabagh: Yes. So that was a clinical trial. When you start with a new treatment, usually don't use that as front line. You want to use it for patients who tried another approved treatment and then when they progressed you go with a new treatment. What was the breakthrough in this clinical trial, so you an immunotherapy proven beneficial in second line treatment. And then patient had to have chemotherapy first and then when they progress, you get immunotherapy. So that the logic question comes well, what if we combine both chemotherapy and immunotherapy, would that be better, two better than one? Would it be toxic? Would it patient be able to tolerate it?

So that was the breakthrough, it's that the principle that adding immunotherapy to chemotherapy is a better option and that got accelerated approval last year. Survival for patients who got the chemotherapy plus immunotherapy hasn't been reached, means these patients continue to do well as compared to the chemotherapy. But then the time til disease progression means the patients who had the chemotherapy and immunotherapy it took them about eleven and a half months before the cancer progressed while the patients who had the chemotherapy only took about 4.9 month before cancer progressed.

The overall response the patients who had the chemo and immunotherapy, were about 48% responding to treatment. That doesn't mean the cancer was gone but was a mix of complete response and partial response, while those who got the chemo only were about 19% response. So clearly, that showed patient had their disease controlled longer and more patients benefited from that combination.

So this was earlier results that the combination got approved as accelerated approval and continued looking and recruiting more patients and was just recently confirmatory trials came back confirming, yes, that was the case. So that makes the combination of chemotherapy plus immunotherapy as first line indication and Stage IV Squamous or Non-Small Cell Lung Cancer.

Leslie Lane: And so that's what made this treatment now available in the physicians offices?

Dr. Sabagh: Correct. And there are other immunotherapy drugs. So immunotherapy is not only one drug, its multiple drugs can be used. Really the question comes as we have all that's hearing that somebody may say, "Why didn't my doctor give me immunotherapy?" It's just because like any treatment, there are indications so first it has to be right kind of cancer and second, there are some conditions where the treatment can do harm more than good specifically someone who has autoimmune disease, something like Lupus or rheumatoid arthritis, not just having autoimmune disease, but an autoimmune disease that's requiring treatment. 'Cause one of the side effects of immunotherapy, it can cause symptoms similar to autoimmune disease in terms of the arthritis can affect other organs so patients selection is important to see the benefit and try to avoid the side effects.

Leslie Lane: What other kinds of cancers are you seeing immunotherapy being used for besides the lung cancer that we've mentioned?

Dr. Sabagh: So the numbers keep increasing almost every week. So, so far it's approved for melanoma, renal cell cancer, Non-Hodgkin Lymphoma, Hodgkin's Disease, bladder cancer, some types of colon cancer. But I think it's altogether it's about eight or nine types that have indication for immunotherapy either as first line or second line.

Leslie Lane: Because cancer is so common, most of us know what radiation means. We mostly know what chemotherapy means. How do you treat with immunotherapy? What does the treatment look like?

Dr. Sabagh: So immunotherapy, it's an IV medicine for the most part. With the most part, I mean there can be some sort of new therapy coming in the future as a pill. We don't know that but now it's available as an IV. So typically, the patient will come see his or her oncologist. If this is the right patient for immunotherapy, the orders are written and our practice we have nurse educator that sits with the patient. Tell them what to expect, side effects, tell them how long does the infusion take in an IV drip goes on for, could be an hour or an hour and a half. And we're done with the treatment.

Side effects we have to watch for because it can develop any time starting the day after two even a few months or several month after the treatment was started.

Leslie Lane: I do want to ask you what those are but you said the treatment is done after one episode?

Dr. Sabagh: It's a session every two or three weeks and it's an IV medicine, IV drip.

Leslie Lane: And so is that a maintenance kind of program or a set time as we might expect with other chemotherapies?

Dr. Sabagh: A maintenance ... it's a phase of treatment. So if we go back to the clinical trial of immunotherapy and chemotherapy, chemo plus immunotherapy were given as IV drip every three weeks four cycles. So this was kind of indiction means, we want to do this more of a stronger treatment and then CAT Scans were done and the patients who responded or had stabled disease they were then given only immunotherapy as maintenance as long as the cancer stayed controlled.

So for immunotherapy, yes, we do use maintenance because we don't know yet how long of that is enough. And we don't know as you stimulate the immune system and you stop how long can it keep going even though it was seen in patients who had side effects from the treatment. And their treatment had to be stopped. They continued to see a response for several month even without treatment. Because that means it isn't like chemotherapy where if you're not adding the chemical to kill the cancer cell, they survive. No, you actually kind of taught the body how deal the cancer cell and the body might be able to keep going for a while before the cancer cell is able to pull another trick and change how it looks to go undetected again.

Leslie Lane: We know that chemotherapy side effects can be really rough on some folks, how do the side effects from immunotherapy compare or is there no comparison?

Dr. Sabagh: It's a different set of side effects and like everything else, really the main thing with immunotherapy is to know what other side effects and to be on the watch for those and you detect them early on so it doesn't become a problem.

So mainly, the immunotherapy, what it does, if you think of cancer cells we see that does evade the immune system, so one of the ways of immunotherapy is it turns on the immune system, so the immune system is active. Similarly, when anyone would have strep throat, and the immune system is active, we have inflammation. Tonsils are enlarged. You're running a fever, you're achy and this is not because of the virus, that's because the immune system is trying to fight the virus. So we basically inducing that immune system to try to fight. So some of the minor side effects could be that the achiness could be some fever, could be inflammation.

Now inflammation if it comes to the gut, would give diarrhea. If it comes to the liver, can cause liver enzymes to go high. Fortunately, most of the side effects from immunotherapy are not what we call grade three or four, means the high grade very dangerous grade of side effects. And the one reason it is that, it's because being caught early and diagnosed early.

And then that's the other thing about the side effects of immunotherapy. It's something makes sense so if we look at that and say, "Well, we have those side effects with immune system was really activated and inducing inflammation. So how can we treat the side effect?"

Of course number one is stop the drug. You know you just want to take a break from that til the symptoms and the inflammation goes down. And then ask a question, if this immune system is on the go, is there a way we can slow it down and the answer is that as steroids. So taking steroids to suppress the immune system, will make someone recover from that. And remember we were talking about autoimmune disease? What do we use for autoimmune disease? We typically use a steroid. Now there are newer treatments for that. So that tells you again why is it if someone with autoimmune disease that's needing treatment, should not be taking immunotherapy.

Leslie Lane: You've talk about some very exciting developments in the area of immunotherapy. What is that progress mean to you as someone who deals with this every day?

Dr. Sabagh: To be honest, I'm glad I'm in practice while this is available. We used to see advanced cancer patients with very limited life expectancy in response to treatment. We're able to see patients now who are getting their immunotherapy for two plus years ongoing and doing well. Of course, there are still other patients who don't respond to immunotherapy or have side effects who have to stop immunotherapy. But overall, truly is a revolution in the treatment of cancer. I hope it will still lead to more refinement and better selection of who will truly benefit so that's your goal is to select the group that will get the most benefit and not to do harm for those who will not likely to benefit from the treatment.

Leslie Lane: Before we close, can you give us a little preview of what you're watching that excites you about other research or developments in the area of cancer treatment?

Dr. Sabagh: For medical oncology the term targeted therapy had been ongoing for many years, that includes immunotherapy and other target therapy targeting proteins on the cancer cell in different ways. So the whole area of targeted therapy different ways of being more specific. How can you combine different ways to attack the cancer cells? So it's shifting from the old way of being like a hammer just keep killing the cancer cells one at a time to deal with this disease in a smarter way, that's what's very exciting now.

Leslie Lane: Well we are grateful to Dayton Physicians and Dr. Tarek Sabagh, joining us today with a fascinating inside look at how we can enlist our own immune systems to fight cancer. If you want to know more, visit premierhealth.com/healthnow. You'll also find a video there of Dr. Sabagh talking about immunotherapy therapy. We'll be back and we hope you will. I'm Leslie Lane and thanks for joining us. Watch for our next edition of Premier Health Now On Air.