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Pediatric Hematology-Oncology Division Offers More Clinical Trials, Options for Treatment

Tiffany Kaczorowski: Welcome to Inside Pediatrics, a podcast brought to you by Children's Hospital of Alabama in Birmingham. I'm Tiffany Kaczorowski. September is childhood cancer and sickle cell awareness month. And today our guest is Dr. Girish Dhall. He is Division Director of Pediatric Hematology and Oncology at UAB, the University of Alabama at Birmingham. He is also a Professor of Pediatrics and leads the Neuro Oncology program here at Children's. Welcome Dr. Dhall.

Dr. Dhall: Thank you very much for having me.

Host: So, I have to just let everyone know that we do sound a little bit muffled and that's because we're masking and we're physically distanced. Just bear with us. Speaking of that, and masking just wanted to bring up a very real situation that we're all in right now with COVID-19. How has that changed things for patients and families within the hematology oncology world?

Dr. Dhall: You know, obviously these are absolutely unprecedented times, you know, we could have never imagined, you know, how it's going to be like or feel like. And we're still learning. And every day it's like something new that we learn or we try to change and so on. But I think first I would like to say that we are as a pediatric or even a pediatric oncology community, we are absolutely blessed that the COVID has not affected our patients as severely as it has affected some of the adults and some other patients who have other comorbid conditions. You know, all of our patients here that have been diagnosed, at least in our division, they have almost, all of them have recovered completely uneventfully. Only one or two patients did have to go to the ICU for some slightly severe symptoms, but even they have made a complete recovery. And we're also fortunate that we haven't had any deaths in our patient population. And two of our faculty Doctors, Wolfson and Johnston, they've actually spearheading a national effort to gather information on pediatric patients with cancer. Who've been diagnosed with COVID at multiple other children's hospitals in the country and their experience from that data gathering has been very similar to ours. So I think we've been fortunate.

Host: Yeah, it's very fortunate. And I would imagine tele-health is part of your world.

Dr. Dhall: Absolutely. Yeah. And I think so the, on that note, while most hospitals, including children's hospital in our hospital, you know, when we went into the intense lockdown phase we canceled all routine surgeries. We canceled almost all routine admissions, and I've been focusing on mostly emergency admissions, but unfortunately for our division for cancer patients, cancer doesn't take a break regardless of what the circumstances are. And then the treatment for cancer just cannot wait. So we did not have the luxury of doing that. So I think we, as a division here at Children's of Alabama, we never took a break. We never, you know, slowed it down. All our faculty, our staff, including our receptionist, nurses, nurse practitioners, physicians, clinical research staff. They've been working through this, our patient volumes never dropped down significantly and they've been on the forefront. And we've also continued to enroll patients on clinical trials because for a lot of the patients that might be the only treatment options. So for that, you know, that really speaks volumes about the dedication of everyone who works in our division. And for that I'm truly grateful and proud of the team.

Host: And I would think to patients who are undergoing treatment, such as radiation, chemotherapy, they're very vulnerable to any kind of illness anyway. And especially in the fall months when influenza starts, I would imagine they have to take a lot of precautions already.

Dr. Dhall: Absolutely, they always do my secret hope is that with, at least from what we've learned from this pandemic, that in all the things that we are doing, social distancing hand-washing and masking, I'm hoping that that's going to help us with even influenza. So I think, I hope that our season is much less severe than before.

Host: You are a neuro oncologist. And so you work with children who have brain tumors and spinal cord tumors, and you guys have developed a neuro oncology fellowship, which means that you'll be training future neuro oncologists, pediatric neuro oncologists. Tell us how important that is to have a fellowship training program here.

Dr. Dhall: Absolutely, leukemia used to be the most common cancer in children that tumor registry studies, you know, brain tumor is now the most common cause of cancer. And it's about one third of all cancer patients in children's also, it is the number one leading cause of death among cancer patients. In addition to that, the patients who have brain tumors, they have unique challenges, you know, so one of the challenges is the effects that they have just from having a tumor in the brain. And then also the long-term effects that they have from treatment, for example effect of radiation therapy on the developing brain, effect of high dose chemotherapy on developing brain, and so on. For most medium-sized pediatric oncology program, it helps to have physicians with subspecialty training in neuro oncology. I think there's definitely a huge need to train pediatric neuro oncologists in the country. And currently there are about 15 or 16 programs in the country that train one neuro-oncologist every year. So then the reason is because not every hospital has all the resources to be able to train the next generation of neuro oncologists. What I mean by that is to have trained neuro oncologists in the program trained neuro pediatric neurosurgeons, neuroradiologists, neuropathologist, and radiation oncologists with specialty in pediatric brain tumors. We are blessed to have all the components of that between Children's of Alabama and UAB. So we're blessed to have positioned here so that we can train pediatric oncologists.

Host: Absolutely. And then when you're talking about training, you've also been working on some global outreach and training physicians from other parts of the world. And you recently had a trainee from Vietnam here, is that correct?

Dr. Dhall: We did. Yeah. So I went to Vietnam last year and saw first hand the resources that they had. And first thing that really stood out was that they really don't have pediatric oncology trained physicians in their program. So as they finish their residency in pediatrics, they just get a job at the cancer hospital and then they just learn on the go you know, it's like more like on the job training, they don't have any formal training. So we have around one to two people who come now from Vietnam Cancer Hospital here in Hanoi to children's hospital here so that they get to see how we do things, how we treat patients, what kind of treatment protocols, you know, we use. So we had one physician who came last year. And so for now, because of the COVID and because of the restrictions with travel, that program is on hold, but we're still in communication with them by emails, if they have any questions that we can help with in terms of treatment protocols, you know, that's ongoing,

Host: Thank goodness for technology and being able to see and talk to people, you know, several years ago it would have been much harder to have that communication.

Dr. Dhall: Oh no, would not be so easy. We never so yeah, it's been, it's been good.

Host: And then the Cairo Cancer Hospital in Egypt, you've formed a relationship with them. So tell us about that.

Dr. Dhall: Yeah, that's been very interesting, and I was just in Egypt just before the pandemic hit in January this year. And I was really blown away by what I saw at that hospital. So they have the patient numbers is phenomenal. And so if we see here around, you know, 200 cancer patients they see like 4,000. So that's a huge number of patients that one hospital sees and they have done a phenomenal job in collecting data on those patients, collecting tumor samples. So there's a phenomenal opportunities for research and so on, collaboration with them. And they are interested in having clinical trials available for their patients. So they are extremely interested. So we are in the process right now of getting what you call a MOU, or a memorandum of understanding, with that hospital. So once all the legal formalities are done, then we hope to formalize our relationship. But in the meantime, we have ongoing again, zoom conference calls once a month. And we talk about how, you know, once this whole thing is settled and how what kind of collaborations that we want to participate in and so on.

Host: Okay. And that leads directly into our next topic, which is consortium's and really the importance of being a part, you know, in the pediatric hematology, oncology world, UAB and Children's are members of several different consortium's, which really helps to be able to elevate the program, but then also helps patients, right? Because then they have more access to different clinical trials, different drugs and therapies.

Dr. Dhall: Absolutely. I think, you know, pediatric cancer is such a rare disease that it's not possible for any pediatric or children's hospital to do clinical trials on their own. That's the reason why we need groups of hospitals to work together in order to conduct clinical trials, because in order to prove or disapprove a point, you know, the strength is in the numbers, you know, for the statistical analyses, you need more number of patients. So each group of these hospitals that comes together to do these clinical trials is basically, that's what we call a consortium. So we're currently members of, I believe five national consortium's. Children's Oncology Group is the largest consortium that we're a part of. And that is mainly responsible for conducting late phase or phase three clinical trials, you know, in children. But then we're also member of one consortium called PEPCI DN or pediatric early phase clinical trials network.

And now this is an NIH funded consortium, just like a Children's Oncology Group or COG. But the mandate of this group is to conduct early phase clinical trials or cutting edge clinical trials with new treatment, new drugs, do different types of therapies in children who do not have otherwise, you know, upfront treatment options. So this consortium has about 20 institutions and we're one of the 20 institutions who have access to these drugs. The other one is what we call the sunshine project. And that's the consortium with the National Pediatric Cancer Foundation. This consortium again, has about 20 member institutions. And what this consortium does is a, again, just like Pepci TN runs early phase clinical trials, but they are mainly focused on bone and soft tissue tumors. So we have a significant number of trials just for these kind of tumors, mostly sarcomas, but we're also members of what we call the NF Clinical Trials consortium or the Neurofibromatosis Clinical Trials consortium.

But this consortium was again formed with funding from the department of defense. And now the difference here is that this consortium conducts clinical trials, again, early phase clinical trials with new therapies and new drugs, but mostly in patients who have neurofibromatosis, it's a genetic condition, you know, that they can have different types cancers patients with this condition. And lastly, we're also a member of what we call the Next consortium. Now, UAB is the coal lead institution for this consortium for the main clinical trial, which is the Headstart 4 Clinical Trial of which I serve as a core principal investigator of this study. And this trial is open at more than 50 institutions across North America, Australia, and New Zealand and so on.

Host: And that's a worldwide consortium?

Dr. Dhall: It is. So for the most part, I think we have good treatment options for patients who are newly diagnosed with cancer. But when it comes to unfortunately patients where the cancer comes back there, the treatment often very limited and they are mainly limited to clinical trials with these new agents or new drugs that have shown promise in preclinical testing in the lab. And so being a member of this consortium allows us to be able to offer these cutting edge treatments to our patients. And that's really very important part of our mission and also something that helps us, you know on a personal level, keep going and be inspired and, you know, inspires us to keep trying new things and to make it make the survivalship better.

Host: I would think during, especially during a pandemic, such as this as well, it's much better on the patient families because they can become a part of a clinical trial like this right here in their backyard, in the state of Alabama, rather than having to travel to another State to receive care, which right now, you know, they're very vulnerable.

Dr. Dhall: Absolutely. And not just from our State, but hopefully also from neighboring States where you don't have to fly in, but it could just, you know, drive down. And so it is absolutely very critical.

Host: You talked about being a principal investigator for one of these new therapies and you are a senior scientist at the O'Neill Comprehensive Cancer Center as well. What inspired you to choose neuro oncology to go into this field and help children with brain and spinal cord tumors?

Dr. Dhall: Yeah, there's, you know, all, each one of us is driven by different things. You know, why we choose to do what we do, but for me it was not very complicated. It was mainly two things. One is when I was training and doing my fellowship in pediatric oncology, I found brain tumors very challenging. And particularly my peers, you know, they, not many people were interested in doing this primarily. So I think that made, made it even more exciting for me to, you know, the challenges, you know, with this tumor type. And the second was working with my mentor Dr. Jonathan Finley, who actually just retired this past week. And he was the director of our program at NYU. And he was a larger, he is a larger than life figure and absolutely extremely passionate about what he does, which is treating children with brain tumors and actually hoping and aiming for a better cure. And I think that's that what really inspired me to go into neuro oncology.

Host: And like you said, there are not many of you in the country. Yeah. So, it is wonderful that you're here and that you're leading the charge. And also that you're going to be training new fellows in this field.

Dr. Dhall: Yes, absolutely.

Host: Tell us about any other advances or news within the division that you'd like to share. Some things that you might be proud of?

Dr. Dhall: The most exciting thing, at least for me, or for our division was that this year we were last year we were able to improve our US News and World Report ranking from 41 in the past to about 27. And this is from about 200 institutions that were ranked. And so that, again, that's not my accomplishment, but that says a lot about the dedication of the people within our division, because I think this just reflects in everybody's work ethic and the quality of the work that we do at Children's of Alabama. So I think that was very good. And a personal level, you know, I was able to publish two very important papers. One of which showed that the patients who had germ cell tumors of the brain, we were able to cure about 90% of them with less radiation therapy than what had been practiced before that clinical trial. And second year of my papers was on the Headstart 3 Clinical Trials. So currently we have Headstart 4 open, but I was able to publish the results from that study, where we showed that we were able to cure around 90% of infants and young children with a particular malignant brain tumor called desmoplastic megillah blastoma without any radiation therapy. So, that was, that was very nice. Yeah. That was exciting. Yeah.

Host: How long does it typically take, or is there no typical time between the time of a clinical trial and when you publish those results, that data, and then when it becomes part of the normal therapy for patients?

Dr. Dhall: So, I think once the clinical trial results are published now, most people would agree that, you know, at that point that becomes like a standard of care for that patient population. So I think these are one of the best results that have been published so far in this population. And so what we are thinking as the next step is to build on this experience and have a joint clinical trial with the European group, with all the European countries. And I will lead the trial from the North American side and we'll have one lead physician from the Europe side. And then again, I think, as I said, the strength of the data lies in numbers. So hopefully we can still be able to replicate at a much larger scale.

Host: Wonderful. Anything else that you want to add?

Dr. Dhall: Other things that I really want to acknowledge three of our faculty received NIH funding last year, and that speaks a lot about the quality of the work that they do. Dr. Greg Friedman, he received an RO1 for his work on modified herpes virus vaccine for brain tumor patients, Dr. Liebensburger. He received his RO1 for identifying kidney disease early in patients with sickle cell disease, and then Dr. Judy Wolfson for her work on leukemia in adolescents and young adults. So it's really exciting to work with, you know, a lot of accomplished people in the division. And it's been a great journey so far.

Host: Yeah. And lots of research and lots of therapies and things are coming out of this institution, regardless of what's going on outside with the pandemic, there's definitely a lot going on behind the scenes to help these children with pediatric cancer and blood disorders.

Dr. Dhall: That absolutely is true. Absolutely.

Host: Well, thank you so much Dr. Dhall for joining us today.

Dr. Dhall: Of course. Thank you very much for having me.

Host: For more information, you can go to our website, www.children'sal.org/cancer, and we will post links to those consortium's Dr. Dhall talked about, and what types of clinical trials are available in the show notes. Thanks for listening to Inside Pediatrics, more podcasts like this one can be found at children'sal.org forward/insidepediatrics.