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Scott Webb (Host): When I first heard about immunotherapy a couple of years ago, for the treatment of cancer patients, it sounded like science fiction. It really did, but it's not. And joining me today to tell us about immunotherapy and how it's being used at Genesis to treat and cure cancer patients, is Dr. Shyamal Bastola. He's the Medical Director of the Genesis Cancer Care Center.

This is Sounds of Good Health With Genesis brought to you by Genesis Healthcare System. I'm Scott Webb. Dr.Bastola, thanks so much for your time today. This is a fascinating topic. I can't wait to roll up my sleeves and dig in here and hear your expertise and explanations and all of that. As we get rolling here, what is immunotherapy?

Shyamal Bastola, M.D. (Guest): Yeah, I know it is exciting for us as well as there's been a lot of development in the field with excellent results for at least some of our cancer patients. So, immunotherapy in general is considered any kind of cancer treatment that helps your immune system fight the cancer. It's a broad category that can include many different kinds of treatments, but that would be sort of a strict definition for it.

Host: Yeah, it is really exciting. I've done a few of these and it's almost sort of mind blowing and I'm sure it is for doctors and scientists as well. And it really does seem like the sky's the limit, but for where we are right now, today, what are some of the different kinds of immunotherapy?

Dr. Bastola: The concept of trying to get our immune system to fight the cancer has been fascinating and has fascinated lots of scientists in the past. And many variety of different kinds of treatments have been tried and continue to be tried, nowadays as well. So, in the old days, you know, we used to use drugs that we qould call immune modulators. These would be treatments that are supposed to excite our immune system, again, with the hope that the immune system will then fight cancer cells. An example of that would be something like an IL2, which would be given as an infusion. It's still being done rarely these days. Then there are, you know, cancer vaccines that are out there being tested as well.

Not as encouraging results with them, but they are being tested. There are what we call monoclonal antibodies. These are medications that sometimes targets specific cells with protein expressions and then let the immune system recognize them, to fight those cells. The more commonly used these days there's something called a CAR-T Cell therapy, which is again another new and exciting kind of immunotherapy out there. It is rarely used, but seems to have excellent results when it can be used, mostly used in lymphomas and more recently in myelomas, still being tested for solid tumor.

These are typically happen at tertiary care centers, because they can be very toxic. But again are being tested for a variety of indications. And we're very excited about that. The most common immunotherapy drugs that are used nowadays are what we call immune checkpoint inhibitors. And these are, for all intents and purposes, when we say somebody is getting immunotherapy or is going to get immunotherapy; in most cases, these are the drugs that we are talking about. There are a lot of them out in the market. I'm sure some of us have heard advertisements, like a Keytruda or Opdivo, Yervoy, things like that. So most commonly these are what we call checkpoint inhibitors.

Host: Yeah, it is so fascinating. And there's just so much to unpack here. I guess, I'm wondering why is immunotherapy and cancer treatment, why is that such a perfect marriage if you will?

Dr. Bastola: Yeah. So again, you know, the idea is in generally, just so the part that comparing to chemotherapy, will patients feel like they're getting a poison to try to fight the cancer? And they're worried about just philosophically so if you compare that to immunotherapy where the concept of just doing something to enhance your own immune system and let it fight cancer, you know, is always, exciting

so it has been, you know, there for a while. What we have learned as time went on is that, obviously there are normal immune system mechanisms to fight cancer. You know that's the reason why, when these cells, normal cells try to turn into cancer cells, they are being surveilled and taken care of. At the same time there's a balance in our body where just like anything else, there are pro immune system proteins and pathways that are happening, but then there are also pathways and protein expressions and things like that to try to control the immune system, because you don't want it to go out of hand which then can lead to more problems. Very similar to how we have pathways to help with clotting, but also bleeding. Cause you'll need them in different settings.

So as time went on, what we've learned is that these cancer cells are using some of these pathways to escape from the immune system. And so, the immunotherapy is trying to utilize the immune system to help fight the cancer cells that may be using normal pathways to escape it. So that's where we think there is benefit there to identify particular kinds of cancer cells that may be using the pathways. And that sort of comes from the basic science research where they can look at different cancer cells and see which ones are using these pathways to escape the immune system. And then utilizing the enhancement of the immune system with immunotherapy to try to get rid of them.

Host: Yeah, it's really cool. I just love listening to you as I'm sure listeners do, just try to explain all of this and you do such a great job, and when we think about the different types of cancer, is immunotherapy appropriate for all types. And if not, what are the types of cancer it is appropriate or best suited for today. And maybe what are you seeing in the future?

Dr. Bastola: A lot of that information obviously comes from the studies that are being done initially to see where it could help. And then, studies being done in actual patients to see benefit. Actually, you know, we're using it in more and more kinds of cancers. It certainly is not for all cancers. What we've learned is that there's some cancers where the immunotherapy doesn't work. Most commonly, something like a melanoma, lung cancer, kidney cancer, that's where we have seen the most benefit, but it is used in other cancers as well, liver cancer, stomach cancer, colon cancer, some of them. There are sometimes certain things, we look at cancer cells. There are certain testing we look at to predict benefit from immunotherapy. So, we can run those tests on the tumor cells themselves as well. But in general, an example of where we haven't seen a lot of benefit, would be something like a pancreatic cancer. We really haven't seen a lot of benefit with immunotherapy, but most of the others, either they're being used routinely and or there are studies going on to see benefit.

Host: Yeah. And you mentioned pancreatic cancer and that's just one that you know, because outcomes and outlook isn't great for folks being diagnosed with pancreatic cancer. And it's one of those we keep our fingers crossed right, that one of these days, whether it's immunotherapy or something else, we're finally gonna sort of crack the code, right.

Dr. Bastola: Yes. Yes. And, and again, I think even with immunotherapy available, there are other studies going on to see, you know, combination of immunotherapy medications, trying to find any other medications that can enhance the immunotherapy benefits. And so I think, lots and lots of exciting studies out there to try to get even more benefits from these drugs.

Host: Yeah. And you mentioned, used the word combinations there. Some I'm wondering if a cancer patient receives immunotherapy, is that the only treatment or is it going to be sort of mixture of things, a trial and error, trying to find just the right combination of things for that particular type of cancer or the specific patient?

Dr. Bastola: Again, a lot of these come from the studies that have been done and tried in patients, so it can be done by itself. So there's certain cancer conditions like lung cancer or melanoma where immunotherapy can be done by itself. There's a combination of immunotherapy as well. What we call a dual checkpoint inhibitors where there are two immunotherapy drugs given at the same time trying to enhance each other. That can be also done. Sometimes we do combine chemotherapy with immunotherapy and there are studies showing that's beneficial compared to chemotherapy by itself in cancers like lung cancer. And then other times we may do one immunotherapy and then follow that up with a dual immunotherapy if the single agent doesn't work. There are some cancers where we have oral medications along with immunotherapy being used as well. So I think it comes in many different flavors. A lot of the research in terms of where it would work or how it works is done in the back end for us. And by the time it comes to the market and we're using it in our patients, a lot of it has already been clarified, by prior studies. But yes, it can be done by itself, as a combination with chemotherapy or combination with other oral medications depending on different settings.

Host: Yeah. And you can just see why there's so much room for optimism and excitement about the present and especially the future with immunotherapy. And this has been really educational today. I wish I could just talk to you all afternoon, but I'm sure you have other things to do, patients to see, and so on. So as we wrap up here, does the Genesis Cancer Care Center provide immunotherapy or do patients have to go elsewhere?

Dr. Bastola: Especially the immune checkpoint inhibitors, we've been doing it since it came out initially many years ago. We have a lot of patients in it and again, we're very excited. There are some patients nowadays, even with a stage four lung cancer that appear to be cured with immunotherapy and actually off of treatment after initial two, three years of treatment, which would be unheard of you know, 15, 20 years ago when I was doing my fellowship. We have quite a lot of experience using it, monitoring patients during treatment, optimizing side effects, if that happens. And we feel like, we're very comfortable using it and are capable of doing it.

Host: Yeah, you certainly are. And I'm just sort of shaking my head the way you said that it was like, you know, curing lung cancer patients is just, it's absolutely amazing. It's mind boggling to think, you know, 15, 20 years ago that that's where we'd be today and really who knows what the future brings. So, Doctor so exciting. Great to hear about all this. So educational, thank you so much for your time and you stay well.

Dr. Bastola: Oh, thank you so much.

Host: Visit genesishcs.org for more information. And thanks for listening to Sounds of Good Health With Genesis, brought to you by Genesis Healthcare System. If you found this podcast helpful, please be sure to tell a friend and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest. I'm Scott Webb. Stay well.