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- Hi, I'm Susan Taylor with Scripps Health
in San Diego California.
More than 40 percent of the people born today
will be diagnosed with cancer
at some point in their lifetime.
Traditionally, cancer has been treated
with chemotherapy and radiation.
But what if we could harness your body's immune system
to actually attack the cancer cells in your body?
It's a relatively new way to treat cancer,
it's called immunotherapy.
Joining us to talk about this today is Dr. Michael Kosty.
He is a medical oncologist, who is Director
of the Scripps Green Cancer Center,
thanks so much for joining us today Dr. Kosty.
- [Dr. Kosty] Thank you Susan.
- So tell us, what is immuno-therapy?
I mean, it came into really prominence
about four years ago, but it has
been around a little bit longer.
- Yeah, immuno-therapy actually dates back
almost twenty years when a drug called Interferon
was used to non-selectively
stimulate your body's immune system.
And by non-selectively I mean
your body's immune system was
augmented or stimulated to try to fight the cancer,
but in addition, it had other side effects.
And so, the concept was a good one,
the execution of it in terms of effectiveness
and side effects was not so good.
It was discovered about ten years ago now
that many cancers have proteins on their surface
that act like camouflage to the body's immune system.
And by that I mean the body's immune system
is supposed to detect things
that are foreign and not supposed to be there,
cancer being one of them.
These proteins on the cancer cell's surface,
camouflage the cancer cells from the body's immune system,
so the cancer grows unabated.
What the immune therapies do is basically
strip away the camouflage
and allow your body's immune system
to then attack the cancer which shouldn't be there.
- So what happened four years ago, that this
kind of just lit up as a really good treatment option?
- Two things happened.
One was the discovery of these proteins on the surface.
- [Susan] Okay.
- And the second was the design of antibodies,
or molecules which would again,
remove these proteins or the effect of these proteins
from the cancer surface so it was a two step process
that occurred relatively rapidly.
And since the development of the first immune therapy drug,
there have been six others
that have come in rapid succession.
- So how is it administered?
Is it like chemotherapy?
How do you inject it?
Is it a drip, how does it work?
- So the immune therapies, like many traditional
chemotherapies are given in the veins,
so it's not an oral drug, or it's not a shot.
They're given either every other week,
or every third week.
Each treatment is relatively brief,
it takes about an hour.
It's very, very rare that patients
have any immediate side effects.
- [Susan] And how long do you take immuno-therapy?
Is it several months, several years,
for the rest of your life?
- [Dr. Kosty] So one of the concepts
of having your body's immune system fight the tumor
is that it takes a while for that
immune response to develop.
Typically it will take anywhere
from two to four months to develop.
So while that immune response is being developed,
patients continue on therapy,
and then typically, they continue on therapy
anywhere from a year to an indefinite period of time,
with the average being about two years.
- Do you do this in conjunction
with chemotherapy and radiation,
or is it instead of them?
- So immune therapy depending on the condition
that we're treating and whether it's
an early stage cancer, or a more advanced cancer,
immune therapy can be used by itself.
More traditionally, it's used in combination
with chemotherapy or radiation.
Both chemotherapy and radiation, it's been discovered,
augment, or enhance the effects of the immune therapy.
- Coming up, we're gonna talk about
how you know if immunotherapy is right for you.
We'll come back to that question
in just a couple of minutes.
But going back to the immunotherapy,
how do you know that you're seeing a meaningful benefit?
I mean, if you say it takes a while
for it to get ramped up?
- So typically, we assess the benefit of a therapy
in a cancer patient in one of two ways.
Sometimes, a specific patient will have
something that you can see externally.
So for example, an enlarged lymph node or mass in the neck.
More commonly though, we do scans,
either a CAT scan or an MRI, or a PET scan,
before the treatment, then we do some treatment
and we do a follow up scan,
and this follow up scan is compared to the prior scan,
and we look and say okay,
things that we saw before, are they the same?
Or are they smaller?
Are there new spots?
Are there no new spots?
And depending on what we see on the follow up scans,
which are done on a periodic basis,
we determine whether the patient is benefiting or not.
- And how long does the benefit last?
- That's really interesting.
- [Susan] The 65 thousand dollar question.
- The unique thing about immunotherapy
is that a relatively brief amount of therapy,
say a year or even two years,
can last many, many years.
So think about the polio vaccine
that you got when you were growing up,
it's effect remains throughout the lifetime.
The current round of immune therapies
may not have a lifetime benefit,
but they certainly have a prolonged benefit,
as opposed to chemotherapy for example where
the benefit that you get at the end of the course
of chemotherapy is kind of what you're gonna get.
There's not a prolonged benefit.
So that really is one of the advantages of immunotherapy.
- Has it changed, the nature of cancer,
in the sense that it becomes a chronic condition?
Something that you live with as opposed to die from?
- That's also a great question.
The early stage of lung cancer,
the goal is to cure, or eradicate the cancer.
In patients with more advanced cancers,
previously, the goals were much more modest.
Trying to modestly extend survival.
These days, our goal is to turn what previously
had been a rapidly fatal condition,
into a more chronic disease, not unlike diabetes,
or high blood pressure, or high cholesterol.
All those conditions, diabetes,
high blood pressure, high cholesterol,
are usually things that we can't eradicate in somebody,
but we can control and allow them
to lead a more or less, normal life.
The same thing with many cancers these days.
- Does immunotherapy work better
on certain types of cancer?
- So immunotherapy really has worked in almost
every cancer that it's been tried in,
with two notable exceptions.
One is breast cancer and the second is prostate cancer.
And both of those cancers, breast cancer
and prostate cancer, are cancers
that are activated by hormones.
Estrogen in breast cancer, testosterone in prostate cancer.
And even in breast cancer now, there are some imerodes
being made with immune therapy,
but pretty much, every other cancer
that it's been tried in, there's been either a small,
or in some cases a really large improvement
in survival in patients with advanced disease.
- And what about cancer that comes back?
Let's say you have lung cancer,
you have treatment, and then it metastasizes
to other parts of the body.
How does immunotherapy affect a cancer when it comes back?
- So that's really where immunotherapy shines
in patients with recurrent cancer
because typically, the tumor has been
exposed on the initial treatment
that was designed to eradicate the cancer.
Been exposed to some form of treatment
and when it comes back, it has
resistance to certain types of treatment.
Typically chemotherapy.
Immunotherapy, that resistance doesn't show,
so it's an ideal treatment for patients
with recurrent cancer.
But again, like everything in life,
the devil's in the details
and you have to really understand
the specifics of your particular
type of cancer and the optimal treatment,
as we talked about a few seconds ago,
might not be immunotherapy by itself,
but might be immunotherapy in conjunction
with something else like chemotherapy or radiation.
- Are there some cancers though
that you can just use immunotherapy
and not have to deal with chemotherapy and the radiation?
Which it sounds to you, is a bit more
toxic than immunotherapy.
- So yes, there are some cancers,
but I think increasingly, we're finding
that for patients to get the most durable,
the longest lasting benefit, immunotherapy
needs to be combined with something else.
But it often allows us to reduce
the dosage of the chemotherapy
that we would use otherwise,
or shorten the number of radiation treatments
that would be required.
So, the net effect is the side effect
are more favorable, less toxic to patients in general.
- Now there's several types of immunotherapy for cancer.
Can you explain what they are?
We're gonna get in the weeds a little bit here.
I know monoclonal antibodies, wanna talk about that?
- Yeah so, monoclonal antibodies
are really targeted to a specific antigen,
or a protein on a cancer cell.
And often times these antibodies
have attached to them a compound
that's toxic to the cancer cell.
So it's a way of, instead of having this
toxic compound go throughout the body,
it's brought directly to the cancer cells.
So you can think of an antibody like a key to a lock
that fits in to a specific part of the cancer cell,
and delivers that so that's more of a targeted therapy
than a specific immune therapy.
The immune therapies that we've been
talking about thus far largely
are therapies which strip the proteins
on cancer cells and allow the body's immune system
to more globally attack the cancer wherever it is.
- So what's vaccine-based immunotherapy?
- So a vaccine in general,
whether it's a vaccine against an infectious disease,
like influenza that we get every year,
or a cancer vaccine, is designed to stimulate
your body's immune system to build up
immunity to the cancer cells.
The problem with vaccines is that
cancer cells change very rapidly
in periods of days or weeks,
and so a vaccine that is developed
for a cancer in a patient four or six months later
may be much less active than initially
because the cancer cell has morphed or changed
so that the vaccine is less effective.
- Is the vaccine-based immunotherapy,
is that used for certain types of cancer?
- So vaccine-based immunotherapies have been
developed for certain types of lymphoma,
which are tumors of the lymph glands.
It's been tried in prostate and lung cancer,
with I would say modest results.
It's I think right now, best
described as a work in progress.
- What about the side effects of immunotherapy?
- So immunotherapy for most patients, for many patients,
is really like taking water in the vein.
It's virtually devoid of side effects.
The most common side effect is fatigue, which is mild.
It's not a fatigue that inhibits
your normal daily activities,
but it is noticeable in many patients.
Other less common side effects are
effects on the GI tract, so people can have diarrhea.
That's pretty uncommon.
Skin rash, that's also uncommon.
And then there are specific organs
that are effected like the thyroid.
So when we have a patient on immunotherapy,
we're not only asking the patients,
how they're doing and how they're feeling,
and examining them for skin rashes for example,
we're also testing in their blood,
their thyroid function and liver function
and kidney function, looking for
these less common side effects.
- And how long do those side effects last?
- If you get the side effects, they can be prolonged.
Typically though, if you take a break,
or stop the immune therapy, those side effects
resolve within a week to a month or two.
- So we talked about this,
I eluded to it a couple of minutes ago,
let's go back to that, holding that thought.
How do you know if immunotherapy is right for you?
- So you'd need to know a couple things.
You'd need to know, is the tumor early or advanced?
If it's early, there are probably
curative strategies like surgery or radiation therapy
to completely eradicate the tumor
and immune therapy would not be appropriate for you.
If the tumor is more advanced,
then there are some tests that can be done
on the tumor itself, looking for these
camouflage proteins I'll call them.
One of the common ones is a protein called PDL-1.
And to the degree that the tumor
has a lot of this PDL-1 on the surface,
that will predict that immune therapy
would be more likely to work.
With certain types of cancers,
and again, lung cancer is an excellent example,
we would combine immune therapy with chemotherapy.
So, it's the type of cancer you have,
whether it's early or more advanced,
and then the characteristics of your specific tumor
in terms of this protein in question,
that have to be taken into account.
- So when you look down the road,
what do you see on the horizon?
- You know, this is really an exciting time.
When I started in oncology, there was a period
of about ten years where virtually nothing happened.
We had ineffective toxic drugs
and we tried every possible permutation of those drugs
and of course, we didn't advance the ball very far.
In the early 2000's and accelerating to now, 2018,
the pace of change has been great.
The consensus I think in most types of cancers
is that the immune therapies that we have available now,
while significant advances are
actually pretty rudimentary,
and if we look down the road not too far,
three, four years, they'll be
different types of immune therapy,
there will be different things
that are combined with the existing immune therapies.
That result of which is patients will do better,
live longer, and have fewer
side effects from their treatment.
Which is a win, win, win.
- Sure is, particularly after you
hear those three words, you have cancer.
Which is just a you know.
- It's very frightening, but I think the thing is,
a patient, if I can give one piece of advice,
is really try to understand as much
as you can about what's going on.
Is your cancer early or advanced?
What are the options that you have
because there are always choices.
There are always options that patients have.
What are the side effects of each option?
And then between you, the care team
that's taking care of you,
and other family members try to come to
some sort of consensus about what's best for you.
You can have two patients with the same condition
in the same stage and they make different choices,
and that's not right or wrong,
it's just what's right for them.
- [Susan] Dr. Kosty, thank you so much.
- You're welcome.
- [Susan] We appreciate your time.
US News and World Report ranks the cancer program
at Scripps Green and Scripps La Jolla,
as high performing in cancer.
That puts us in the top 10 percent of hospitals nationwide.
If you want more information about immunotherapy
and cancer treatment on Scripps,
please click on the link.
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I'm Susan Taylor, thanks so much for joining us.
We appreciate you being with us.
It's our mission at Scripps to help you heal,
enhance, even save your life.
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