Dr. Ralph Boccia, Medical Director at the Center for Cancer and Blood Disorders at Georgetown University talks about a new way to outsmart cancer without using chemotherapy.
Interview conducted by Ivanhoe Broadcast News in 2023.
Your patient, Barry Taylor, told the story about how he went initially to a physician who seemed to indicate he didn’t have a treatment for him, and then he found you through a contact of his. Is that good advice for people because you all are subject to what you read, what you learn, what you experiment with? Is that correct?
Boccia: Well, I think we all have training that varies depending on what institution you trained at. And then of course, during our training, we can have a certain focus after you go through the more or less general training that you might for hematology or oncology, or today, most training programs are hematology and oncology combined. But different institutions have different focuses on different types of cancers that may relate to their clinical research or may relate to their faculty interests. And so there are some differences in our training, and I would like to say that there are better institutions to train at. That some have the opportunity to go to, and some that have programs that are probably a little bit less well thought of.
So, as a physician, what do you think about patients that ask a lot of questions?
Boccia: Well, today everyone is better informed given the worldwide web, right? So it’s pretty easy to find information, it’s not always correct information. Dr. Google isn’t always correct. But it is pretty easy for people to search out experts, to search out different training options, to go and read about what different institutions might try to inform the lay public of. So there’s just a lot of useful information out there. The problem is, you have to be able to interpret it.
When Barry first came to you, what were you thinking, in terms of treatment for him at that point?
Boccia: So, when we approach a patient with chronic lymphocytic leukemia, we have certain parameters that we use and guidelines that we use when to actually initiate treatment. Chronic lymphocytic leukemia is essentially an incurable disease. It’s a low-grade leukemic process that happens to be the most common leukemia that we see in the Western world. And as a low grade, we call them lymphoproliferative disorder, so that could be lymphoma or chronic lymphocytic leukemia. Those diseases, cancers, tend to be incurable, but they tend to be slow growing, so people can live many years with them. And often patients may not need treatment or be symptomatic from it for many years. So if you have a disorder that isn’t causing symptoms and isn’t curable then in knowing that treatments tend to get better with time, it’s often in the patient’s best interest not to be treated. So people may come and say, oh my God, I was just diagnosed with chronic lymphocytic leukemia, how can you tell me that I should just be observed? I have cancer, Doctor. Why are you saying this to me? Well, again, since therapies get better with time and since not everyone has symptoms that bother them in the least, then it’s in the patient’s best interests to wait until they have a need for the therapy. They do not in any way, shape, or form have a downside for that except in a very, very small fraction of patients who might have one, we call it a transformed lymphoma or leukemia, where it goes from a low-grade to high-grade process. But treating the lymphoma early does not prevent that. So again, it comes back to if you don’t need to be treated, maybe you don’t need to be treated. And there are plenty of patients with this category of lymphoproliferative disorders they may never need to be treated, may live with, and die with, but not from these cancers. So Barry, when he first came to me, had a elevated white blood count, he was not anemic, his platelet count was fine, he didn’t have big swollen lymph nodes, he didn’t have a big enlarged spleen, he didn’t have night sweats or fevers, his weight was steady, he wasn’t losing weight. So he basically was found to have this by accident, so we had no symptoms. So we were able to follow Barry for several years before he developed those symptoms and signs that caused me to say and to talk to him and say now it’s time to start treating your chronic lymphocytic leukemia?
What does this type of leukemia, chronic leukemia, look like inside of the body?
Boccia: So, it’s a disorder that starts typically in the bone marrow and involves the lymph nodes in any part or throughout the body. It involves what we call the reticuloendothelial system. So the reticuloendothelial system is the bone marrow, the blood, the lymph nodes, the spleen, and the liver so all of them can be involved with this. Your spleen and liver can enlarge, your bone marrow can become packed up with the leukemic cells, so you don’t have normal bone marrow formation, and you could become anemic. Your platelet count can fall and because it’s a leukemia, the white count rises. So we have people and Barry was one of those who, since he’s had several relapses, has had some time, some very enlarged or what we call bulky lymph nodes and a very enlarged spleen because of leukemia.
Barry mentioned taking treatments for, sometimes, three to four hours at work while he’s on there with the drip, what is happening during that treatment time?
Boccia: They’re sitting and resting in a recliner chair or they’re being monitored by our infusion nurses. Hopefully not having a lot of side effects from the drugs and often just either watching TV or working on their computer or sometimes sleeping, taking a nap.
But as that drip comes down, what is that drip doing inside of the body to tackle it?
Boccia: Well it depends on what the drip consists of, Barry has had chemotherapy at times, has had a lot of biologic therapies that engage the patient’s immune system to kill all the cancers. And he’s had some very targeted therapy that block signals that are telling the cancer to grow, so block the signal cancer regresses.
Do you know where this comes from or originates?
Boccia: We don’t know what the cause of chronic lymphocytic leukemia is. Interestingly from the Second World War and the atom bombs in Nagasaki and Hiroshima, there were higher incidence of CLL that occurred after that, but other than that, and the genetics in some families. There are families with familial or genetic chronic lymphocytic leukemia also, other than that, we don’t know what causes CLL.
You mentioned the interaction with the liver, the disease seems to happen with people not eating properly and battling obesity. Does anything of that nature cross paths?
Boccia: Not really, this is an infiltrated process. So these lymphocytes, these cells infiltrate the different organs that mostly again the liver and the spleen or the lymph nodes themselves and cause enlargement. And sometimes if it’s really advanced with the liver for instance, it could be some liver failure that could occur. Doesn’t occur that often because usually we can control it.
What are you treating Barry with right now?
Boccia: So, he’s on a targeted drug called to acalabrutinib, a monoclonal antibody called Obinutuzumab, and another targeted drug called Venclexta. So, he’s on three drugs; two of them are oral and one of them is intravenous.
How do you make that determination on mixing those three particular?
Boccia: Barry’s history has been pretty interesting, he’s always been willing to and has participated in a number of our clinical trials. We’ve been pretty much involved and engaged as almost a practice mission to help develop new drugs, and be able to offer our patients cutting edge therapies and drugs even before they get released by the FDA approved. So he’s been on a number of those trials and has benefited from a number of those trials during his 10 year journey basically.
As a physician, how does it feel to you to be able to offer hope to somebody?
Boccia: Well we like that, the more we pride ourselves in always having options for patients when there are possible options out there. And we’d like to be able to try to provide them ourselves, opposed to sending them to cold and sterile places where they may not have the same experience.
How do you find out about new cutting edge treatments?
Boccia: Well I also happen to be the Chief Medical Officer for a 4,500 or 5,000 member community-based oncology network in the entire country. So I am, one of my responsibilities is to put on clinical or educational meetings. So I have to, and I go to all the, I go to the Congress and the American Society of Hematology, American Society of Clinical Oncology, read a lot of journals and participate in live discussions and then drug development. And I have a fairly large national and a relatively small but definite international footprint, where I sat on a number of drug development boards with different colleagues throughout the world. And you learn from each other, you network with each other, you participate in some of these great trials.
And in relation to this particular disease, what has been the most astounding thing that you found out?
Boccia: So, I think the journey that we’ve gone through with chronic lymphocytic leukemia and starting with chemotherapy, we basically virtually never use chemotherapy anymore in this disease. We only use the biologic therapies and the targeted therapy. So chemotherapy is a thing of the past, pretty much for chronic lymphocytic leukemia. So that’s pretty astounding. The therapies, after we transitioned from chemotherapy to these targeted therapies, we went from fairly fixed duration therapies to now take it until your disease gets worse again. So we call that treat to progression, progression of the cancer. And now we’ve come full circle where we’re realizing we could put some of these combinations together, and we can give them limited therapy. Therapy that would might last only a year or two so that they have treatment holidays that may last years.
That’s very sad. He’s been on a couple of those treatments nowadays. And he said he’s actually come back after that, just the body to learn from the treatment and in a bad way.
Boccia: Well the cancer learns from the treatment, the cancer, treatments cause a certain pressure on the tumor that causes them to look for escape mechanisms, develop mutations that now make them resistant to the drugs that we use.
What would you say to someone watching this on any options that they should or could pursue if they’ve been diagnosed?
Boccia: But I think just the discussion with their hematologist about what are the treatment options out there? What are you thinking of? What will, what will this look like next time? The other thing that I didn’t get to is we are actually getting to some therapies that could point us toward cure. So we’ve gone from a chemotherapy era to a biologic era, to a targeted era, now what we call cellular therapy. So we have new therapies where we can engage our T cells, here everybody knows what T cells are, I think these days because there’s so much on the news and everything else. But these therapies now we call them CAR Ts, and we can actually extract these from the body by a filtration process called leukapheresis. We can then harm them against a target that’s on the cancer cell and then infuse them back in the body, they can attach to the cancer cell and then engage the T cell and the T cell can kill the cancer. So we’ve really come a long way in the last 10 years, a long way. There are lots of different advocacy groups where they can learn, lots of the groups they can get together with them, and a lot of us will go out and speak at them and they can learn what’s new and available and sexy out there.
END OF INTERVIEW
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