Cancer immunotherapy has changed the landscape of cancer treatment for the better. However, not all patients are aware of what exactly cancer immunotherapy is, or the potential benefits that immune-based treatments might offer for them during the course of their care. From checkpoint inhibitors to CAR T cells to vaccines, to the promise of clinical trials and the exciting emerging science of the microbiome, cancer immunotherapy has the power to save many more lives and bring us closer to a world where we can cure all cancers.
For the tenth anniversary of Cancer Immunotherapy Month™, the Cancer Research Institute (CRI) aimed to bring people up to speed and help the general public understand the basics of cancer immunotherapy better presenting this webinar for patients and caregivers discussing the “Top 10 Things Patients Need to Know about Immunotherapy.” To highlight both the scientific and patient perspectives, we brought together Laurie H. Glimcher, M.D., the president and chief executive officer of Dana-Farber Cancer Institute, and Sunshine Pegues, a CRI ImmunoAdvocate and lung cancer veteran, in a conversation with CRI’s assistant director of scientific affairs, Arthur N. Brodsky, Ph.D.
Together, they discuss insights relating to the various types of immunotherapies, CRI’s Clinical Trial Finder, how gut health impacts cancer and how it responds to immunotherapy, and much more including:
- Who can be treated with immunotherapy?
- What factors affect cancer development and immunotherapy responses?
- Where can patients find immunotherapy clinical trials?
- How are vaccines used against cancer?
- What are the potential side effects of immunotherapy?
- What is genomic testing and should patients ask for it?
- And live questions from the audience!
Laurie H. Glimcher, M.D., a longtime member of the CRI Scientific Advisory Council, is the president and CEO of the Dana-Farber Cancer Institute, as well as the director of the Dana-Farber/Harvard Cancer Center and the Richard and Susan Smith Professor of Medicine at Harvard Medical School. During her career as a distinguished immunologist that has seen her publish more than 350 papers, Dr. Glimcher has been inducted into many prestigious organizations, including the National Academy of Sciences, the National Academy of Medicine, and the American Academy of Arts and Sciences. She has also received numerous awards, including the American Association of Immunologists Lifetime Achievement Award and the L'Oréal-UNESCO Award for Women in Science, and CRI’s William B. Coley Award.
In 2011, Sunshine Pegues was diagnosed with stage 4 non-small cell lung cancer. Standard treatment at the time was chemotherapy followed by 35 days of radiation, which burned the skin on her neck and left her in more pain and skeptical about the advice of her health care team. She moved back to her hometown, Seattle, where she enrolled in two clinical trials. The second trial tested nivolumab (Opdivo), an anti-PD-1 immunotherapy, which stopped her cancer from progressing and eventually, caused it to become inactive.
The Cancer Immunotherapy and You™ webinar series is produced by the Cancer Research Institute and is hosted by our assistant director of scientific content, Arthur N. Brodsky, Ph.D. The 2022 series is made possible with generous support from Bristol Myers Squibb with additional support from Alkermes, BioCanRx, and Lilly Oncology.
Browse our Cancer Immunotherapy and You Webinar Series playlist on YouTube or visit the Webinars page on our website to see other webinars in this series.
Webinar Transcript
Arthur Brodsky, Ph.D.
Hello and welcome everyone to the Cancer Research Institute "Cancer Immunotherapy and You" patient education webinar series. I'm your host, Dr. Arthur Brodsky, assistant director of scientific content at the Cancer Research Institute, and during today's webinar we'll be focusing on the "Top 10 Things Patients Need to Know about Immunotherapy" with the leader of one of the world's most prestigious cancer centers, as well as one of our CRI ImmunoAdvocates whose life was changed by immunotherapy. Toward the end, we'll also have time to answer some questions from those of you in the audience, so if you have any, please enter them in the Q&A box below.
Before we begin, I'd also like to quickly thank the generous sponsors of this webinar series: Bristol Myers Squibb, as well as Alkermes, BioCanRx, and Lilly Oncology.
Now, it is my pleasure to introduce today's featured guests. First, we have Dr. Laurie Glimcher, the CEO and President of Dana-Farber Cancer Institute, as well as a longtime member of the CRI Scientific Advisory Council. During her career, she's made numerous contributions to the field of cancer immunology, and has also sponsored 5 CRI postdoctoral fellows.
We are also fortunate to be joined by Sunshine Pegues, a CRI ImmunoAdvocate who lives in Seattle, Washington. In 2011, Sunshine was diagnosed with metastatic lung cancer, and first underwent chemotherapy and radiation therapy, before later receiving a checkpoint inhibitor immunotherapy known as nivolumab or Opvivo, that targets the PD-1 pathway. So, without further adieu, I will pass it off to you, Dr. Glimcher so we can get started.
Laurie H. Glimcher, M.D.
Thank you, Arthur. And I'm delighted to be here to join this wonderful conversation with Sunshine. Let me give you a just a brief overview of immunotherapy and the different types of immunotherapies that we have. First of all, let me let me say that it took us over a century to come up with ways to activate our own immune system. Probably, in most cases, cancer cells that arise in our bodies get killed by the immune system. But that doesn't always work. And that's the genesis of cancer.
About two decades ago, we started to be able to activate our immune system to kill off cancer cells in those patients with cancer. And the biggest immunotherapy are drugs called checkpoint blockers. And these are antibodies that bind to protein on the surface of the key cell, the key immune cell in the immune system, it's called a T cell. And those antibodies activate those T cells, so that they can kill off the tumor. And that's really the majority of immunotherapeutics that we have, and you've probably heard of them with names nivolumab (Opdivo) and pembrolizumab (Keytruda), and so on (ipilimumab/Yervoy).
And these two receptors (PD-1 and CTLA-4) that are so critical were discovered by Dr. James Allison at Berkeley, and by Dr. Gordon Freeman at Dana-Farber Cancer Institute, and they have really made a big difference. We can now treat about 25% of patients with these checkpoint blockers. But we also have other things in our pocket that are going to hopefully allow us to increase the percentage of patients who will respond to immunotherapy and bring it from 25% up to 100% we hope. And that includes cell therapies, those are living drugs, so called CAR T cells, and in that therapeutic, we take blood from the patient, we take out those very important cells called the T cells, the killer T cells, expand them, and then we genetically manipulate them so that they will, when infused back in the patient, they will go directly to the tumor and kill the tumor. And that has shown some very, very good results.
Right now, we can only use it for hematologic malignancies (blood cancers), like acute lymphocytic leukemia (ALL) or lymphoma. But many, many scientists from both industry and from academic medical centers, are trying to develop ways that we can also use CAR T cells for solid tumors like lung cancer or kidney cancer, so on. And then there are several others. We're working hard on vaccines, therapeutic vaccines, oncolytic viruses, bispecific antibodies that you can infuse in people that will drag the T cell right to the cancer cell and stick them together and activate that T cell to kill the cancer cells. We can expand on that further later. But Sunshine, let me turn it over to you because you've experienced this.
Sunshine Pegues
Yes, I have, and thank you so much, doctor. One of the things that's very nice I would like to share that is for me very earth shattering, and that is that immunotherapies today are currently approved for 15 major cancer types. And they're also approved for children. Some of these cancer types include bladder, breast, head and neck, kidney, lung--as I had--and stomach cancer. And this is a major breakthrough, when you think about over the last decade or two, that we actually have this proven approach that we can use to help us in our fight with cancer.
Laurie H. Glimcher, M.D.
There have been really wonderful steps forward in immunotherapy, including that immunotherapy can also be approved for tumors, regardless of their origin. And when I say that, we call it solid tumor-agnostic approaches. And this is precision medicine, precision oncology.
Let's take, for example, colorectal cancer, which is pretty resistant to immunotherapies. There are 15% of colorectal cancer patients, however, who have what we call high tumor mutation burden (high TMB). And those 15% have a DNA repair incapability, which means that they're having trouble repairing their DNA. And when that happens, you get a lot of tumor mutation burden. And it turns out that those people who have what we call DNA repair high tumor mutational burden, they respond to immunotherapy. So that's a small percent of colorectal cancer patients. But this is also true across all cancers. For example, breast cancer that arises from BRCA mutations and so forth [might be more responsive to immunotherapy]. So, this type of approval -- for tumors regardless of their origin -- is new.
Sunshine Pegues
And one of the things that I would like to share is, when I was first diagnosed over a decade ago, the situation was a little different. But today, immunotherapy really doesn't need to be the last resort. There are trials out there today for all different types of cancer and at various stages. When I went through the trial, it was a stage 4 situation. But that was a decade ago and that just shows the evolution in time that you don't have to wait now and use it as a last resort. That is a major breakthrough.
Laurie H. Glimcher, M.D.
And then we come to another really interesting approach and that is vaccines. Now, we're all familiar with vaccines like tetanus and pertussis and measles, mumps, rubella, and those are our preventive vaccines, or the COVID vaccines, which help us from becoming infected with COVID. And these are what we call preventive vaccines. But what we're working on right now is therapeutic vaccines. Can we make a vaccine, a cancer vaccine, that will arouse the activity of that T cell, that T lymphocyte, which is such a key player in killing cancer cells. We and others have been able to do that for cancers like melanoma. We had a clinical trial at Dana-Farber for a melanoma cancer vaccine. And what we do for that is to figure out what are those foreign proteins that are on the surface of the tumor, but they're not on the surface of normal cells? And can we make a vaccine against those foreign proteins? And the answer is yes, you can. You do it as a personalized way because the foreign proteins that are present on each patient could be somewhat different. And when the trials showed that a number of patients who had melanoma that had spread widely, and that were sort of out of options, responded to this vaccine, particularly when we do it in collaboration with the checkpoint blockers. We'd love to have preventive cancer vaccines for our children and grandchildren, and maybe we'll get there, but right now we're focused on therapeutic vaccines and we're developing more for ovarian cancer, for glioblastoma, which is brain cancer, for kidney cancer. I think this is a very fruitful field that is moving forward right now.
Arthur Brodsky, Ph.D.
I just want to hop in real quick, at the halfway point. For those of you who might have joined a little late, I just want to remind you that we are taking questions from the audience that we'll get to toward the end of our webinar. So, if you do have any, you can enter them in the Q&A box and we'll try to get to as many as we can. Back to you, Sunshine!
Sunshine Pegues
Thank you. As a patient or a patient advocate, you hear a lot about trials. And one of the things that's very challenging is how did you find out about these trials? I mean, how do you stumble into it? There's no stumble. What I'd like to point out is that CRI has a Clinical Trial Finder that can help patients find out about trials. And this service is free. I know when I went into the trial, it just happened that my oncologist knew about it. But as I mentioned earlier, there's been so much evolution, and people should take advantage of this Clinical Trial Finder that CRI has, whether you are the patient or whether you are the advocate, to help people find out about these trials that are out here.
Laurie H. Glimcher, M.D.
One area that scientists are really looking hard into is what's the role of our bacteria, the so called microbiome? How is that related, or is it related, to the onset of cancer or the treatment of cancer? Our intestines, our skin, our mouth are all full of millions and millions of different species of bacteria. And most of those are very good bacteria that are helpful to us, some of them are bad bacteria. There's been a tremendous output of data on what does the microbiome look like in patients with cancer, and what is the response of immunotherapies to cancer? Is it linked and correlated to the kind of bacteria you have in your in your colon or you have in your skin? And the answer is yes. These bacterial species, there are certain bacterial species that actually promote the efficacy of immunotherapies, and there are other bacterial species that hinder the response to immunotherapy. And we have a long way to go, but we do know that high fiber and high bacterial diversity, lots of different kinds of bacteria are linked to responses to nivolumab (Opdivo) or to pembrolizumab (Keytruda). And while some other species actually are linked to resistance to immunotherapy, so that's also a field that is being explored because we wonder, can we provide those good bacteria to people who aren't responding to immunotherapy will that allow them to then respond?
Sunshine Pegues
For cancer patients, one of the major concerns are side effects of the treatment. There's been a lot said out there, people who have experienced a lot. I know I personally experienced side effects with traditional treatment. But when it comes to immunotherapy, it has side effects, but they're very mild. And that's all dependent on the person. But they're mild, and they're reversible. And for me personally, and I'll talk about this a little later, that's probably one of the major "a-ha!" moments, was that there was pretty much no side effects when I was going through the trial. That, for people who have gone through traditional chemo and traditional radiation, that was such a blessing, to be able to not have to go through staying in bed, other things that I'll talk about later, but the lack of the side effects, of the severe side effects, was tremendous. So, I do want to share that. And like I said, everybody's different. Nobody can say there's never going to be, but on the on the most part, there's very little side effects, they're mild, and what side effects they are, they're mostly reversible. And I hope that helps people, you know, understand there is a big difference between immunotherapy and traditional treatments.
Laurie H. Glimcher, M.D.
We are continually developing and increasing our understanding of the immune system. The immune system is so important in killing off tumor cells. It's also important in killing off viruses, as we all have experienced during the COVID-19 pandemic. And we need to continue to look for new immune-based therapeutic approaches. And that's really one of the major focuses of what cancer centers are doing now, including our center, Dana-Farber. Because there are other ways that you can activate the immune system. If you look at a tumor, and you look at it under the microscope, you'll find that the tumor itself is surrounded by-- if you think of the tumor as a castle, and there's a moat around it, and that moat is filled with other immune cells. There are many cells in the immune system that are very immunosuppressive because the tumors secrete various proteins and hormones and so on that can suppress the rest of the immune system. So, sometimes those important T cells cannot get through the moat, to kill the cancer in the castle. We need to figure out ways to reverse the immunosuppressive cells, both innate and adaptive immune cells. So, there's a focus on trying to figure out how do we clear this moat away and turn it into strong, active, anti-cancer, immune behavior.
Sunshine Pegues
Last thing I'd like to point out is, when someone is diagnosed with cancer, your mind just sort of goes. There's no doubt you're just overwhelmed. Even your advocates could be overwhelmed. One of the things that I found very important that helped me and I hope would be something that people would reach out to, is to have assistance in navigating this journey. Whether it be your, like I say, your advocate, but it's very important. And I can talk a little bit about my journey, and the resources I had available to me, because otherwise I would have been just totally like this is too much for me. I'm just trying to stay alive and you guys want me to figure all this stuff out. I mean, our minds just can't do that. I would like you to know that there's organizations like CRI has an ImmunoCommunity that's there available to you to help you journey through this. Understand that we all go through it. We all get overwhelmed. We all are like why, what, where, we got a thousand questions. And we need that assistance, because there are experts out there and people that have networks that can help you. And I would just like to point out that if I can say CRI has an ImmunoCommunity that can help you maneuver through this. And it's not us being weak, it's not us not being able to do what we normally can do. Because we're all strong, but we just don't know. And we do need that assistance going through this journey. And I just wanted to throw that out as the last thing before we go into more specifics.
Arthur Brodsky, Ph.D.
Thank you both so much for that, it was very informative. Just a quick scan of the Q&A seems that it elicited a lot of follow up questions, which we'll get to soon. But first Sunshine, I want to start with you, and I want to follow up on the clinical trials. How was your experience on an immunotherapy clinical trial? And what else would you want people to know about them?
Sunshine Pegues
As I mentioned, mine was like a decade ago. It was still relatively new, I was in a phase 1b trial, which that meant there was 50 people in the country doing the trial. A lot was unknown. But I had a very positive experience. As I mentioned, I had no real side effects. One of the things that I think is very important, whether you're doing a trial or not, is that you really are open and honest with your oncologist and any physician's assistants that may be working with you. When I first went into the trial--and I'm going to be totally transparent here--I was sort of turned off because I had a very negative experience with the traditional treatment. My neck got burned through radiation. And I just was like, 'Oh, I don't trust you guys.' And so I had to build a very strong bond with my oncologist. And I was very open asking questions, provide me the documentation. I'm not asking for proof it's going to work because it's a trial, but let me know what I'm facing. They were very open with me, they were very supportive. They understood my hesitation. And as far as the trial itself, probably the worst part of the trial was it lasted 20 months. The sense that I was getting treated every two weeks or getting poked. But other than that, I'm happy to say I've been declared NED, no evidence of disease. And once I got through with the trial, I haven't had any treatment since so I'm very blessed for that and very happy and definitely am an advocate for participating in trials.
Arthur Brodsky, Ph.D.
That's great. Another important aspect of clinical trials, in addition to evaluating the potential of new treatments, is that they allow us to improve our understanding of the relationship between cancer and the immune system, and how treatments can affect this balance so you can get closer to cures for more people. So, Dr. Glimcher, from your perspective, what are some of the most exciting areas of innovation that are currently being explored in the clinic?
Laurie H. Glimcher, M.D.
Well, I'm excited about some of the new antibodies that have been generated now that activate the T cell, that really important cell in cancer. And there are quite a few new potential checkpoint blockers, not just against those two receptors that I mentioned earlier, but against other receptors that inhibit these inhibitory receptors. And there are several out there now that are being tested. And there was one (the anti-LAG3 relatlimab) that was just approved about a month or so ago that had identified a new protein on the T cell that could be targeted, because we don't want only 25% of our patients to respond to immunotherapy. We have to continue to innovate and find out different ways that we can activate those T cells. That's something that I am very excited about. We are also making progress in CAR T cells as think I mentioned earlier. These are a living drug that you take those T cells from patients and activate them outside the body and then infuse them back in. As I mentioned, that only works for liquid (blood) malignancies like leukemia or lymphoma. We want to make sure that we can target solid tumors as well with CAR T cells. And that's a very, very active field right now, with just some hints of success, most recently in pancreatic cancer. As I said before, we want 100% of our patients to respond to immunotherapy, so we have to keep on doing our research, our basic research and translational research, to find new approaches that haven't been discovered yet, because I think there's a lot there to still discover.
Arthur Brodsky, Ph.D.
Sunshine, we have a question about side effects. Obviously, everyone has a different experience, but what side effects did you experience when you received immunotherapy, if any?
Sunshine Pegues
As I mentioned earlier, I really didn't have that much. Initially, the first six months, because it was still new and they didn't know, I was basically coping what I would call isolation. I wasn't allowed to leave my house. And then after the six months, it was like, okay you're not having any reactions--because as I mentioned, it was a very early stage trial--you're not having any reactions, then go back to resuming your normal life and just come in every two weeks. The one thing I do want to point out, and this isn't a physical side effect, because as we said, there's not many physically, but there are emotional side effects because you're dealing with the unknown. You really have no- it's like, is this working? Is it not working? The fact that I don't have any side effects and I'm used to having them. What does that do? And I would just like to say that's normal, too. One of the biggest things my oncologist told me after the trial was I needed to learn to live. Because a lot of cancer patients--and I admit I was there, stage four, I was preparing to die. And he said, now you've got to learn to live. That's what I mean by psychological side effects. You do have those, but physically, I didn't really have much.
Arthur Brodsky, Ph.D.
Just real quick, a follow up. We might not think of this as a traditional side effect, but was there any change in your energy levels? Did you find yourself more tired or fatigued?
Sunshine Pegues
Not after the first month or so. And I mean, I walked, I didn't do strenuous activities, but I did do walks during the week, etc. to keep that up. I ate normal, so no not really.
Arthur Brodsky, Ph.D.
That's good to hear. So, Dr. Glimcher, side effects are an especially important consideration for young patients whose bodies are still growing and developing and maturing. What do we know about the possible advantages of immunotherapy compared to other treatments when it comes to the impact that they can have on children?
Laurie H. Glimcher, M.D.
That's a great question. This could have an enormous effect on children. Children do not in general, respond to the checkpoint blockers, which is the major source of immunotherapy and what Sunshine, of course had and did so well with, has not worked very well in kids. And that is in part because of the different way their DNA is organized. Most adults have single genetic mutations that lead to cancers. Children tend to have a different way of producing tumors where you're getting bigger shuffling around, so they're different. Kids aren't just little adults. But what has worked in children is CAR T cells. And that's so important when you think about side effects because if you have a child with acute lymphocytic leukemia, the traditional treatment is with chemotherapy and radiation. And for a small person who has a lot of growing still to do, they have a higher risk of having secondary cancers, they have a higher risk of other unpleasant side effects that could stay with them. But CAR T cells is a living drug and it has been successfully used. In fact, it was really the first patient, it was a little girl with ALL who went into complete remission. I think the future for pediatric cancers that do respond to CAR T cells is a very bright one. I can envision a time that the side effects that chemotherapy and radiation therapy have on a child as that child grows into an adult, if we can get rid of those side effects by using CAR T cells, think how important that would be. Especially important in something like brain cancer in children. Because if you're radiating and chemotherapeutic and so forth, you're going to have some cognitive side effects that could be very severe.
Arthur Brodsky, Ph.D.
So, I'm going to kind of combine a few questions that are going around this. You've both mentioned-- Sunshine, you mentioned some of the cancer types of which immunotherapy is likely to work better. And Dr. Glimcher you mentioned that we can treat about a quarter of the patients so far with immunotherapy. So, I guess the first question is what more needs to be done to expand expand immunotherapy's benefits to more patients? And then also, even in the cancer types like pancreatic or glioblastoma that we think don't traditionally respond to immunotherapy, some patients do. And so what ways are there for patients to learn about these rare successes and what insights could they draw from them?
Laurie H. Glimcher, M.D.
You're right that only 10 or 12 tumor types respond to immunotherapy, about a dozen tumors that seem to be very receptive to immunotherapy. But there are other tumors, like pancreatic cancer, colorectal cancer, the majority, and other tumors that really don't respond well to immunotherapeutics. And this is where fundamental research is so important, because we have to figure out why do patients with pancreatic cancer not respond? And one of the assumptions we've made is that that moat that is sitting around the tumor is just so immunosuppressive that T cells can't get into there. So, how do we reprogram that very toxic immuno environment? Think of it as a micro environment around that tumor that blocks it off from those important T cells. So, how do we reverse and reprogram that environment, that hostile environment that sits around a tumor like pancreatic cancer? And I think we're making some progress in that. And that involves looking at the immune cells, not just T cells, but other immune cells as well.
Arthur Brodsky, Ph.D.
Now, I want to turn to a concept that we've implicitly been discussing, but haven't really mentioned explicitly, and that's biomarkers. Obviously, the most important thing is you want to see if someone's tumor shrinks or not, that's the goal. But there's a lot of other things, a lot of other pieces of information that can also help guide doctors’ decisions. And biomarkers are what we call these pieces of information. So, Sunshine, I'm curious, I know like you mentioned, it was a decade ago, but did your doctors ever discuss this concept with you?
Sunshine Pegues
It's funny you ask that because, yeah it was a decade ago, and I'm going to blend a couple of things in with this answer. The trial I actually participated in was not meant for lung cancer, the actual drug trial, and a couple of us advocated to just give it a shot. I want to throw that out there that not all trials are immunotherapy drugs are identified ahead of time what cancer type they're for. We were some of the first to do it for lung cancer and going back to what you said, I did my trial at an alliance. And so part of this--and I had to give permission--was for the research arm to actually, every time I got my treatment and the results were read, they were looking at the different markers. They were looking at how things were progressing. And granted, they didn't know my name, I was identified by a number, but one of the outcomes and I sort of chuckled at first because not all trials are successful. And I'm pretty honest here, out of the 50 people that participated in my trial, I'm the only one still around. And through the process, as people were dropping out, I was giving my oncologist a hard time going, 'yep, you know, this trial's not too successful.' But what he did, and this is kind of tied to your question, is he told me, he said what they were able to do from researching my markers, it was pretty much identified who the drug would work on. And so that was a benefit, not just for me and my success, but it was a benefit as far as the evolution of the drug to understand who they can actually give it to and it be successful. So, yes, it was continually going on and even every scan I had for up to nine years. This research arm, Fred Hutch, was actually researching my results and refining what was going on as they were monitoring me. I hope that answered your question.
Arthur Brodsky, Ph.D.
That was a great explanation. I want to turn back to the microbiome here because I think it's such a new and, frankly, surprising concept that the bacteria in our stomach and our intestines can influence how our immune system responds to cancer elsewhere. And specifically, one person mentioned that their husband is about to undergo immunotherapy. While we mentioned that the bacteria can influence immunotherapy responses, Dr. Glimcher, what do we know, even though it's still early, what actionable steps or recommendations are possible to give at this moment?
Laurie H. Glimcher, M.D.
Well, there have been some trials for patients not necessarily with cancer, but with, for example, something like a bacterial infection. As I said, we have good bacteria and bad bacteria, and clostridia can cause disease in the gut. There have been a number of studies where the fecal material is transferred from a healthy person into a person who has been infected with Clostridium which has sort of overtaken all the other bacterial species. And that fecal transplant appears to be successful in some cases. Because as I said, there's good bacteria and not so good bacteria. And the question is, can you overcome the bad bacteria by putting in an infusion of the beneficial bacteria. Most bacteria are beneficial for us, we need them, they help keep our immune system active and they prevent illnesses. So, it's not like bacteria is bad. It's not, it's mostly good. There have also been experiments--but these are done in mice, so this is a preclinical test--seeing if the transfer of bacteria from a healthy mouse into a mouse with cancer makes a difference. And I think the field will define bacteria, bacterial species, that are useful in combating cancer. It's an explosive field and a lot of work is being done. I don't think we have the therapeutics yet.
Arthur Brodsky, Ph.D.
Totally agree that there's lots more to be explored, but in the short term, for patient who is just going to receive immunotherapy without the fecal microbiota transplant, as you mentioned, or FMT, are there any foods or anything one could include in their diet to maybe boost their chances of responding to immunotherapy?
Laurie H. Glimcher, M.D.
That's a big question. I'm not really in a position to say what you should eat or not eat. But I think the U.S. nutritionists-- there are healthy diets, and diets that are not very healthy. There is an increased risk of cancer, for example, if you eat a lot of red meat. Fiber is good. If you if you look at other populations, sometimes from developing countries, where the majority of their diet is high fiber, those individuals seem to have a lower cancer rate. So, we want to always be sure and have a balanced diet that includes lots of vegetables and fruits, and fiber and not too much red meat.
Arthur Brodsky, Ph.D.
We mentioned earlier when you were talking about chemotherapy and immunotherapy and the side effects in children-- I don't want to, we don't want to give the impression that chemotherapy is bad and doesn't have a place in treatment. And I know that more recently, we've started to see the benefits of using them both together. I was wondering if you would mind explaining that.
Laurie H. Glimcher, M.D.
Chemotherapy and radiation therapy has saved the lives of millions of people. And when Dr. Farber, Sidney Farber first proposed to treat kids who had acute lymphocytic leukemia, 100% of them died. And he said, let's try chemotherapy. And he was got a lot of pushback from other physicians saying this is going to be very toxic for these children, and you shouldn't be doing it. And Dr. Farber said, well, we need to take that chance, because 100% of these kids are going to die. And so he went ahead and tested chemotherapy, and he saved the lives of some of those children. And then it was realized that just giving one chemotherapeutic wasn't enough. If you gave several different chemotherapies that greatly increased the survival of kids with ALL. With chemotherapy, I would say 95% of children will do fine with chemotherapy, so let's not throw it out. We're not throwing out the baby with the bath here. Combination therapy is the future of cancer treatment, combining precision drugs that target specific genetic mutations. That's been a real success. That was another revolution that was next to immunotherapy. So, if you know that your cancer arises from a mutation in a specific tumor gene, if you can make a drug that disables that mutation, that's been an incredible success. I think, again, it's combination. We want to use drugs that attack a specific genetic mutation, we want to activate the immune system, we want to do cancer vaccines, we want to do CAR T cells, and it's going to be the combination that is going to lead to a much bigger success in treating cancer in more patients.
Arthur Brodsky, Ph.D.
Along those same lines, I want to get back to you Sunshine. You brought up the biomarkers that can help doctors figure out what are the specifics of an individual's disease and their biology, their immune health, and then Dr. Glimcher you mentioned there are a lot of options, a lot of potential treatment options. And traditionally cancers have been treated based on where they arose, what organ they came from, but we're starting to move toward a more tumor agnostic setting and really treating a tumor based on its underlying biology rather than just the organ where it arose. And I think one of the amazing things about this is that it can help bring people with rare cancers into the fold, who might not have been able to get into a clinical trial or we don't have enough science on. So, how is immunotherapy helping to improve care for these patients, too?
Laurie H. Glimcher, M.D.
As I mentioned earlier, based on the patient's tumor burden, the number of mutations that a patient has. The more the more mutations that are there, the better that tumor will respond to immunotherapy. That's an overstatement, but it's roughly correct. And that makes it tumor agnostic. It doesn't matter if it's a lung cancer, or a sarcoma, or whatever. If that patient has a very high burden of tumor mutations, they're much more likely to respond to immunotherapy. That work was done by a wonderful scientist at Johns Hopkins and was published in the New England Journal of Medicine, showing that you could consider tumors as tumor agnostic. Doesn't know what it is, as long as it has certain characteristics that suggest it will respond to immunotherapy.
Arthur Brodsky, Ph.D.
Such a promising time. Everyone's cancer is different. And now we're finally starting to get the tools to be able to treat people in the way that's most likely to benefit them. So, we've got time for one last question, and I want to turn to you Sunshine. I know the science has come a long way in the last 10 years. But as far as patients either going on a clinical trial or just regular treatment, what kind of things should they ask, whether it be about biomarkers or other aspects of treatment, if they're potentially going to get immunotherapy?
Sunshine Pegues
There's a few things and they come in different categories. I think it's very important for patients to understand from their insurance, or if they don't have it, how is this going to be? What's the financial impact? So there's no surprises. One of the things I had to ask my insurance was-- I'm going to be honest, having scans every six weeks is not a cheap endeavor. Is that covered, and what's the cost going to be to me? And not that it was going to make a difference, because I had to do it, but you need to understand the financial impact of whatever it is you're going on, whether it be traditional or non-traditional. When it comes to the actual medical side of it--and I'm saying this from experience--I would always recommend you have a second person there with you. Someone who can take notes, because like I mentioned earlier, your mind is just gone and you don't hear a lot of things or you think you hear something that's not really there. It's very important to be able to write down your questions, specific questions you have, and have the answers, but also have a second set of ears. Be sure to understand these doctors are working for you, so it is your right to ask and, not challenge, but ask them to explain things not in medical terms, but in lay terms. What is going to be the side effects? One of the things that I actually did, and like I said it was a decade ago, but when my neck started to get burnt, I had to question what's going on? Why isn't somebody monitoring this? And finally, they were like, oh, we need to stop the radiation because it was too hard. But remember, you're your own advocate. And I do think it's very important. And the most important thing is to have that second set of ears. But understand the financial impact, understand the side effects you're going to have, understand what is the expectation. For example, my doctor when I went to Seattle and started going to the Cancer Care Alliance there, they were preparing me if this happens, you need to go to the emergency room and I was like, why are you telling me this? And so they explained it. So, I just say ask anything. You don't know. There's no dumb questions. It's your body. But go into it with open eyes. And remember, most of the caretakers, they want to impart their knowledge. But like I say, have them do it in lay terms because I'm not a doctor. Spilling stuff to me in medical terms means nothing. Tell me what I'm gonna feel. Tell me how much it's gonna cost, what's going to be my time commitment, etc. What are my expectations? And if you don't know, that's great. Because I had doctors say we don't know what's going to happen next day. We don't know. You're in a trial, we're gonna find out together. But build that rapport so you can be honest about it.
Laurie H. Glimcher, M.D.
I just wanted to say one quick thing before we say goodbye. And that is financial burden should not be a deterrent. And at Dana-Farber, we have removed financial barriers from treatment because everybody deserves the best cancer care. And this is a top priority at Dana-Farber, making sure that every patient, no matter what their zip code is, can come to Dana-Farber and know that we will take care of them.
Sunshine Pegues
That is awesome. Thank you.
Arthur Brodsky, Ph.D.
Absolutely. And then just real quick, before we wrap up, Dr. Glimcher, I was wondering if you wouldn't mind just providing a vision of what you think is in store for immunotherapy in the near future?
Laurie H. Glimcher, M.D.
I think it is just the beginning of immunotherapy. The more we learn about the immune system and how to harness it and activate it, I think we're going to add many other cancers to immunotherapy treatments. I think the future for cancer vaccines, CAR T cells, new checkpoint blockades is just-- we're going in an exponential way. It's a really amazing time for cancer. This has been, over the last 20 years, there's been a revolution in both precision oncology and in immunotherapy, and we will get there. We will get there because we're also going to try to detect cancer early. Think about that. Only 25% of our patients come to us with stage 1 cancer. We can cure stage 1 cancer. 75% come when the tumors have already spread, and then it's harder to treat it. So, early detection technology, just checking somebody who, for example, has an inherited risk of cancer. We want to test that person early on for any signs of cancer so we can treat them right away. And we can extend that to anybody with high-risk of cancer.
Arthur Brodsky, Ph.D.
That's great to hear. And hopefully we'll get there very soon. And like Sunshine's shirt says, usher in a Future Immune to Cancer. Thank you so much for sharing your perspectives and insights with us Sunshine and Dr. Glimcher. For more of our webinars and the additional resources we have for patients and caregivers. As part of CRI's Answer to Cancer educational programs, we encourage you to check out our website at cancerresearch.org/patients. Here you can read and watch stories shared by others who have received immunotherapy treatment across a wide variety of cancer types. You can browse our entire library of past webinars and our Immunotherapy Patient Summit Series, featuring the world's leading immunotherapy experts as well as others who have received immunotherapy. You can access information on resources including treatment, emotional support, and financial assistance. And, as Sunshine mentioned earlier, you can find help locating an immunotherapy clinical trial. I'd also like to thank our sponsors Bristol Myers Squibb as well as Alkermes, BioCanRx, and Lilly Oncology one last time for making this webinar series possible. And thank you all for your attention today. I hope you found today's webinar interesting and informative. Again, you can watch this and all of our other webinars on our website at cancerresearch.org/webinars to learn more about the immunotherapy options in a number of cancer types. Finally, Dr. Glimcher, Sunshine, I want to thank you both so much again for helping to highlight this exciting field of cancer immunotherapy as well as the patient perspective and the opportunities that immunotherapy offers for people with cancer. Thank you!
Sunshine Pegues
Thank you.
Laurie H. Glimcher, M.D.
It's a pleasure.