Leukemia

Speaker 1: Welcome to Bench to Bedside, a weekly series of live conversations about recent advances in cancer from the research bench to treatment at the patient's bedside. And now your host and the director of the University of Kansas cancer center, Dr. Roy Jensen. Roy Jensen: Hi, I'm Dr. Roy Jensen. Thanks for joining us for today's episode of Bench to Bedside. With me today is Dr. Tara Lin, the director of our acute leukemia program at the University of Kansas Cancer Center, and medical director of our clinical trials office. September is blood cancer awareness month, so it's an ideal time to call attention to advances in leukemia care. And today we're going to focus our discussion on a specific leukemia subtype, acute myeloid leukemia, or AML. Dr. Lin, could you please tell us what is AML and why we're seeing it in the spotlight lately? Tara Lin: AML is a blood cancer, which means that it comes from the cells in the bone marrow. Normal bone marrow makes all of the healthy red blood cells and infection fighting cells that you need for your body to function. But in the case of leukemia, the cancer cells replace those normal bone marrow cells. So people develop symptoms rather quickly of anemia, such as shortness of breath, or fatigue. They can develop infections, or they can even develop bleeding. And that's why it's such a medical emergency for us to diagnose it and get treatment started quickly. This is a really exciting time in AML. The standard of care treatments for AML were developed in the early 1970s, and for 40 years there really weren't any changes in how we treated the disease in the newly diagnosed setting. In 2017, we had four new drugs approved for AML after almost 40 years of not having any real advances, and we've actually had one more drug already approved so far in 2018, and we're expecting several more to come before the year ends. So it's really an exciting time in AML treatment and biology as we discover these new findings in the lab and we're able to quickly bring them to patients in the clinic. Roy Jensen: So that's really exciting that we've had all these developments. Prior to that though, when it hadn't changed for so long, what would you say was the critical thing that patients need to understand about fighting AML, and what's the best chance for them to have a positive outcome? Tara Lin: AML is really a rare cancer, and so it's important for patients to be treated at a center that actually specializes in AML. In recent years we have seen studies and publications saying that getting treated at a high volume center, a center that treats a lot of patients with AML, being treated at an academic center, being treated at an NCI designated center actually improves outcomes. So that's without any new drugs or any new treatments, just being treated at a place that specializes in AML can result in improved remissions and longer survival. What's important to know is that in a large volume center it's not just the doctor and it's not the drugs in the bag that might be different, but it's an entire care team. So our pharmacists here at the University of Kansas Cancer Center specialize in leukemia, in those chemotherapy drugs, what those toxicities are. Our nurses specialize in taking care of patients who are getting this kind of chemotherapy. Our financial counselors are equipped to guide and counsel patients on the challenges of treatment. Our social workers are infectious disease specialists. Our ICU physicians are all highly trained to take care of these patients. We know the side effects of treatments, we know the complications, and we're really able to offer a comprehensive, focused team with experience of taking care of patients with AML. Roy Jensen: So that's very helpful. And it totally makes sense that the more cases that an institution treats, that they'll be better at it. So if you're just joining us here, we're with our leukemia expert, Dr. Tara Lin, and we're discussing acute myeloid leukemia. And Dr. Lin mentioned that studies show patients achieve the best outcomes when they obtain treatment at large volume academic medical centers. So let's talk about academic medical centers and kinda what role they play. How do they make such a big difference, do you think? Tara Lin: By being part of an academic medical center and being part of an NCI designated cancer center, we really have access to the most innovative and cutting edge clinical trials. A clinical trial is a study of either brand new medicines or older medicines in new combinations that can help bring new treatments to our patients. We had so many years when no new drugs were approved, but we were certainly working very hard to change that. And all of that comes through clinical trials. So the five recent drug approvals that we've seen all took many years of development through clinical trials. And by being in a cancer center that has access to trials, our patients get access to the latest treatments more quickly, maybe even before they're approved. When we think about our program here in AML, our goal was really to develop a comprehensive program, and our goal is to have a clinical trial for every patient. When you go to the national guidelines for how we treat AML, at every stage of the disease, the first choice is gonna say clinical trial preferred, because our treatments aren't yet good enough. So it is important to have treatments in a clinical trial setting for patients with newly diagnosed disease, with relapse disease, for younger patients, for older patients. It's important to have that comprehensive program in order to bring the best treatments to our patients here in Kansas City. Roy Jensen: So is there a certain type of patient with AML that would qualify for a particular trial? Tara Lin: We work really hard to have a large portfolio of clinical trials for all of our patients with AML. Some people are older, some people have additional medical problems in addition to their AML, like heart problems or diabetes, who might not be able to tolerate more intensive treatment. And so we wanna have clinical trials that fit each one of those slots. We wanna have trials for patients who are going on to stem cell transplants, trials for patients to get additional treatment after their stem cell transplant. And so we really look at each individual person and help design the best treatment for them, whether that includes a clinical trial or standard therapy. But our goal of the program overall is to be able to have clinical trials for all of those major categories of disease. Roy Jensen: So you mentioned bone marrow transplantation. How would you, if you were at a center that didn't offer bone marrow transplantation, how do you think you'd be approaching AML? Tara Lin: We certainly take care of a lot of patients through our transplant center where we didn't diagnose their AML and we didn't take care of them in the upfront setting. The key to identifying and getting patients quickly to transplant who are really gonna benefit from it is early access and early referrals. And so we work to have a big transplant program so that we can work with our referring doctors across Kansas, Missouri, Oklahoma, to be able to bring those patients sooner rather than later so that we can work together to identify a possible donor and help to work with them to put together a longer term treatment plan. The AML newly diagnosed part is just the first part of the equation, and there is years of treatment for most of our patients. And so it's looking at each individual and figuring out what's the right upfront strategy, where does transplant come into play, what additional therapies can we offer them to give that whole continuum of care. Roy Jensen: So I think you make a great point about having a large portfolio of trials to individualize treatment for patients. And I totally agree with you. I think access to bone marrow transplantation is essential for a patient who's gonna be treated for acute leukemia. Maybe, could you tell us more about the role of personalized medicine in leukemia? And that's a topic we're certainly hearing a lot about these days, and so what does that mean for AML, personalized care? Tara Lin: When we think about where AML has been to where it is now, we originally used to diagnose it just by looking at slides under the microscope based on the size and shape of the cells, and that's how we would subtype people. And now we do sophisticated chromosome analysis to help guide us in prognosis. And now we're using what's called NGS, next generation sequencing, to look for gene mutations. I would say 10 years ago it was standard of care to test for 3G mutations, and now, as the field has grown and we've learned more about what these mutations mean to the overall outcomes of the disease, and as we have specific treatments targeted to these mutations, the importance of having rapid NGS results or gene mutation results is more and more important. What we've done here at KU is work with our laboratory team and developed our own in-house panel. So we have reviewed the literature and determined what we think, based on all the studies, are the most important genes that are gonna guide us in the treatment of a patient's AML. And so we've developed a 141 gene panel that we run in house. There are several genes that would change what I would do in the first several days of treatment, and we have worked with our lab so that we get those results in house 24 to 48 hours, including Saturdays and Sundays. And that's just such a priority. If our disease is so different than it was 40 years ago, we have all of these new treatments, the key is to be able to figure out which patient matches with which new treatment, which patient matches with which kind of clinical trial, based on those profiles. And recognizing how important it was to the field and to our individual patients, we took the approach of developing this panel in house and guaranteeing that we really have a rapid turnaround so that we can act upon this data quickly for each individual in front of us. Roy Jensen: So if you're just tuning in, we're talking to leukemia specialist, Dr. Tara Lin, and we're learning more about how AML care has recently become more personalized. Dr. Lin, do you think this trend is gonna continue? Tara Lin: I sure hope so, absolutely. It is crazy to think that from 1973 'til early 2017, we treated all leukemia patients the same when they walked in the door. We know so much more about leukemia biology and we have so many new drugs and strategies at our disposal. That is only gonna continue to grow as we learn more and conduct clinical trials, to be able to bring those exciting laboratory discoveries right to our patients. Something else that I think is important as a take home message is the data suggesting and demonstrating that getting treated at a large volume academic center with access to transplant, access to clinical trials, can improve outcomes. Recognizing that, we have developed what we call the acute leukemia hotline, which is a referral phone number for physicians to call and get directly in touch with our leukemia physician to ask and answer questions, to facilitate transfer if someone needs to come here urgently during the middle of night, to facilitate transfer if someone needs to be seen in our clinic, to talk about available clinical trials. If I'm gonna sit here and say that being treated at our center is gonna improve outcomes because of the data that we've seen published, it's incumbent upon us to make it easy for the docs across the state to get in touch with us. And that was the drive behind the acute leukemia hotline, and it's really been a huge success being able to be that referral source for our patients. And then also, to be able to just keep the lines of communication open between all of us. Roy Jensen: Well, all of that progress is very exciting to hear about, and I wanna congratulate you and really the entire heme team for doing such a wonderful job with our patients. So thank you Dr. Lin, that is all for today. And we appreciate you joining us, and we invite you to tune in next week, Wednesday at 10:00 am, for Bench to Bedside. We'll actually be filming from Chicago at the Annual Association for American Cancer Institute's meeting as we discuss with Jen Pegher, the new executive director, the future for that organization. Parenthetically, I would add that I have the honor of being the new president for the AACI, and certainly look forward to working with Jen and to hearing about some exciting new initiatives that they have on the way. So thank you for watching and please tune in next week.