Transplant Nephrologist at University of Washington & Fred Hutchinson Cancer Center, Dr. Christopher Blosser, talks about a new clinic that can help transplant patients who’ve developed cancer.
Interview conducted by Ivanhoe Broadcast News in 2023.
Tell me about the cancer and organ transplant, and what makes it so special.
BLOSSER: The cancer and organ transplant clinic is the first of its kind, a multi-disciplinary clinic that provides personalized care for people who have cancers before or after an organ transplant. The reason it’s special and the reason I built it is that people have a much higher risk of cancer in the setting of organ failure or organ transplant, two to four times higher risk than the general population. Oftentimes their care is fragmented or siloed. For instance, I’ll see a patient here at the university for transplant care. If they have cancer, they will see an oncologist or a surgeon, or a radiation specialist at Fred Hutch. That often leads to siloed care that doesn’t provide the best chance for them to do well. I built this clinic as a multi-disciplinary clinic where those patients see the right oncologist or surgeon with the right transplant doctor in the same clinic. Then we provide recommendations back to their team in order to continue that care, whether it’s here in Seattle or somewhere else in the country.
Beyond the obvious, what are the problems, the pitfalls of having this siloed care?
BLOSSER: There are a number of limitations to silo care. The first is that people have to spend more time traveling to different clinics. Communication isn’t always optimal between providers, even when they mean to do their best with their communication. Sometimes patients don’t get the care they intend or was intended for them. Patients sometimes make efforts to compensate by communicating back and forth between providers, but that doesn’t always cover the details in ways that are best. Then the care plan can be compromised, especially in these high-risk patients that need immunosuppression lifelong to prevent rejection of their organ while getting the best cancer treatments, some of which are intended to amplify or wake up the immune system to directly attack the cancer.
Is this the only clinic that is offering this setting for cancer patients with the organ transplant mean?
BLOSSER: This is the only functioning clinic that brings cancer care together with transplant care that we know of in the world.
Break it down for me, if a new patient comes in here, what kind of care can they expect to receive?
BLOSSER: A patient can refer themselves or their provider can refer them to be seen. Once we receive their referral, then we can determine which doctors need to see them. We customize their appointment to be based on their needs so that based on their cancer, a certain cancer doctor with that expertise will be scheduled to see that patient as well as the right to transplant doctor in the same clinic on a half-day. The patient can expect to be here for half of a day in the afternoon. There’ll be seen by one of those doctors and then the other. Sometimes a third is necessary. Then the providers meet in a conference room to discuss the patient’s condition and come to an agreed-upon recommended plan for them that we can then both tell the patient about and pass back in writing to the providers that they’re involved in. That means that when we go back to the patient that same afternoon at the end of the day, we have a coalesced plan that we think is best for them. We coalesce that plan around their life goals. Some people really want to conquer cancer even if it means a risk of rejection of their organ transplant, while others don’t want to take that rejection risk. We really consider what the patient’s goals are when it comes to our recommendations. Naturally, we can have them follow up with us in the clinic if they need that. Then they’ll go back to their provider team, cancer team, and transplant team with the understanding of what we’ve recommended. We communicate with those providers in writing and talking with them so they know what we’re thinking.
Can you give an example of how this has been basically a game changer for some patients?
BLOSSER: One patient whom we had the chance to meet was dealing with a certain type of cancer before a potential kidney transplant, and already had kidney failure. We found this cancer in the midst of evaluating her for a transplant. She had a friend who is willing to be a living donor for her. Everything was waiting for her from the transplant perspective, yet she really needed to be safe enough from the cancer perspective to go forward down the transplant. Certain cancers are at higher risk to progress or redevelop after a transplant when someone is on immunosuppression and others are safe. Our evaluation with this patient was for her to come in and meet a cancer specialist based on her experience as well as then a transplant doctor in that case, me, to clarify her risks and potential benefits. We were able to determine that her cancer was under control with current treatments and that her risk of progression was safe enough that she could proceed with a kidney transplant. She received that transplant about three months later. Now it’s been about eight months since their transplant. She’s doing well with no signs of recurrence and is incredibly happy that she’s off dialysis and living a better life. A different example is a patient whom we met in the clinic who had a kidney transplant now over 10 years ago. As he aged, he was starting to notice trouble passing urine as he was before and came to find that he has prostate cancer. Initially, he made a plan with his local doctors on how to treat it. Yet he had some concerns about whether or not that might cause an injury either through surgery or radiation to his kidney transplant. He called us and we offer that he could talk with me and a urologist and the prostate cancer oncologists about his condition. He came into our clinic and we were able to really evaluate his cancer at the current stage, the optimal therapies. He was then able to decide whether he wanted cancer or radiation. In his case, he decided to go forward with surgery in order to prevent the radiation that might have been a problem for his first kidney transplant.
I was told that a patient had mono, I think it was also known as MGUS, and you are able to catch something that wouldn’t have been caught otherwise?
BLOSSER: It was in one of our publications. I was more vague in terms of that first case I talked about and that may be the same one you’re referring to. There’s been a number of people whom we’ve cared for in our clinic who have monoclonal gammopathy of uncertain significance or potentially significant to kidney function. Sometimes those people need treatment to really control those proteins that are abnormally flowing through their bloodstream before they can get a kidney transplant. If we don’t treat it, they can have kidney injury after the transplant and be right back in the same position of needing dialysis. I’ve met a number of people including a man who came in with MGUS. The question was whether or not it was safe for us to transplant him based on his level and type of protein. In our workup, including doing a bone marrow biopsy and a kidney biopsy, we were able to clarify that he actually was safe and had minimal protein of a type that was easily controlled in the setting that he had. He’s gone on to get a kidney transplant and is doing well since the transplant as well.
What do you think the outcome would have been realistically for some of these patients if they had done more of what you call siloed care?
BLOSSER: I think one of the problems that we need to face is that many people are living with chronic conditions that are going to cause death unless we can do better for them. Cancer is a scary thing that often can lead to death depending on the speed by which the cancer grows. At the same time, kidney failure, heart failure, and liver failure also cause death. We’re walking a fine line to try to help someone live in the midst of more than one potential life-threatening condition. By bringing together the providers that are experts in those situations, we’re more likely able to save someone’s life from both and achieve a better quality of life and a longer life for them than if they are seeing a doctor to talk about their cancer, who isn’t necessarily aware of the implications and the risks of death from organ failure and vice versa, the transplant doctor who may not be familiar with the cancer therapies that are available to optimize that patient’s treatment.
Is there a what’s next for this clinic? Do you have bigger plans? What’s the next step for that?
BLOSSER: My goals for this clinic are to continue to serve a greater, larger population that needs this. Part of that goal is to reach people in other states who currently don’t know about what we can offer, and telemedicine is a part of how we can do that. I’m working to get licensed in multiple states to be able to provide that service, Alaska, Montana, Idaho, and Oregon. Tomorrow I’m seeing a patient from California who learned about our clinic and is coming up here to see us. The more we can get the word out, the more people we can serve around the country and potentially beyond.
Is that hit upon all the areas?
BLOSSER: I would love to highlight how our clinic also is integrated with our research program and our bio-registry in order to serve the long-term goals of our work. At the same time that I built the cancer and organ transplant clinic, I also created a research center named the Center for Innovations in Cancer and Transplant. The mission of that center is to establish a bioregistry, which is now live, and the only patient-level national registry to address the many questions that we don’t have good answers for, as to why people develop cancers to a greater extent in the midst of organ failure and with immunosuppression, and how we can optimize their treatments to achieve better outcomes potentially with targeted therapies and immunotherapies for cancer. While trying to tailor their immunosuppression to prevent rejection and also give them the chance to live the best life and overcome the cancer they have.
Do you know the percentage of patients who go on to develop cancer?
BLOSSER: We know that people after organ transplant are two to four times higher risk for cancer compared to the general population. At least 15 percent of organ transplant recipients will develop cancer within 15 years of their transplant. As we do better in keeping people alive after transplant, they’re unfortunately more likely to develop cancer because of their survival. Through that, we have a greater responsibility to a greater number of people who are living longer.
Is there anything else you wanted to speak on?
BLOSSER: One of the things that we have built into our cancer and organ transplant clinic experience is that when we go back to present our recommendations to the patient and their loved ones in the room, we ask their permission to record that interaction with an audio recording. Then we take that audio recording and give them a flash drive of that conversation that they can take home with them in case they don’t remember the details of the conversation. Oftentimes that leads to follow-up questions that they may have not followed about amid the stress of the interaction.
Could you talk about how toxic some of the therapies are for cancer, for the immunosuppressive, and the toxic qualities of them that patients have to deal with that for transplant?
BLOSSER: One of the reasons that I study the intersection between cancer and transplant is because every person who ends up receiving an organ transplant needs to take immunosuppression for the rest of their life. While it’s great that they have the opportunity to live a better life with the transplant, there are multiple side effects of the medications they have to take every day, oftentimes multiple times a day. Those medications intentionally suppress the immune system which leads to greater risks of infection, including COVID, and also increased risks of cancer. Many people develop diabetes, they gain weight. All of those risks are part of every person’s life after transplant, it’s not a cure. It’s a decent treatment but I think we can do better. Unfortunately, as we’ve done better with cardiovascular prevention and infection treatments, more people are developing cancers. We don’t know enough about how to tailor immunosuppression to prevent cancer while still preventing rejection. At the same time that immunosuppression is needed to prevent rejection if someone develops cancer, those treatments are also harsh on the body. Chemotherapies have always been harsh and I know that thankfully we’re moving towards more precise cancer therapies such as targeted molecular therapies and immunotherapies. The immunotherapies have taken off in terms of their success in the general population. Unfortunately, they activate the same immune system that we need to suppress to prevent rejection in our organ transplants. They do the opposite effect, with that, the immunotherapies can cause rejection unintentionally. One of the purposes of the cancer clinic is to address that risk before immunotherapy has started, so that patients can make informed decisions about what they want to do in that context, and we can help to prevent rejection while optimizing cancer therapy even with immunotherapy as much as possible. All the while we’re learning every single patient, while we learn with the patient how to best use those treatments in the future.
END OF INTERVIEW
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