Dr. Young Chae, associate professor of medicine at Northwestern Medicine, and Dr. Ankit Bharat talk about Lung Transplants for lung cancer patients.
Interview conducted by Ivanhoe Broadcast News in June 2022.
Would your normal patients for lung transplants not be someone with cancer?
CHAE: Right. Lung cancer surgery is an option, but the resection, just taking out the tumor, is really the answer, usually. I guess transplant is giving you the new lungs. You would have to be in immune suppressed status to avoid rejection from the foreign lung that you’re, in your body. Usually, cancer is a contraindication, and we fear that the cancer will come back if we transplant new lung to patient with history of cancer. We don’t like to do it with advanced lung cancer where there may be a seed somewhere in your body that the cancer would grow back.
What gave you the idea to do this with Albert?
CHAE: We met Albert, who had a unique case where his lungs were filled with cancer cells, but it didn’t spread outside lung, not even to a lymph node nearby. We thought this was a special case and deserved special attention because when we say advanced lung cancer, usually it spread outside one lung. His case is advanced because it had spread to the other side of the lung, but it didn’t spread, also, to distant organs like liver or bone or brain.
Did you feel like you were working against the clock before it spread then?
CHAE: He stood the test of time that he was getting multiple different lines of medical therapy. We saw that his cancer cells did not spread outside lung. It kept spreading inside the lung to the opposite part of the lung. He couldn’t breathe well. In fact, he ended up in ICU, intensive care level care was required.
Is there a hesitation to do a lung transplant with someone who is already compromised from chemo and radiation or whatever he was going through?
CHAE: Yes. A lot of patients suffer side effects from chemotherapy or other systemic therapies like immunotherapy or targeted therapy, so it might not enable them to get to transplant. We understand that. But he was able to tolerate all these treatment to a point where transplant could still be an option.
What led you to that decision? It was a double lung transplant?
CHAE: Right. Because both of his lungs were affected, it to be double. He went to many different institutions asking for that. Obviously, even I, on the first visit, told him upfront that advanced cancer is really not an indication. Or it is, rather, a conventional contraindication for lung transplant. But he was very persistent. Asking, “Can you reconsider?” I reconsidered and really found this case to be a unique and rare case that we could work together.
Do you think this is something that you might consider in the future? Is this something that is going to open the door for more people to have a chance?
CHAE: Yes. We do believe, he is not the only one. We are now getting referrals from, the United States and outside the United States. We are planning to open this registry where we will explore advanced cancer as an indication for our study and follow these patients closely.
Have you seen Albert since the surgery?
CHAE: Yes.
Is it surprising?
CHAE: It is rather surprising because I am used to treating advanced cancer patients. Although I do my best to extend their life, we give them quality of life for a few months to a few years, so they can meet their life goals. Going to a graduation of their loved ones. I’ve been doing that, but I’ve always seen lungs filled with cancer, shrinking, then growing. Just to see a new lung, clean lung, is surreal. It is a really good experience.
Is he cancer free now?
CHAE: He just needs surveillance, which is just doing a CAT scan every three months. We do trace any molecular signs of cancer coming back from his blood. And that also has been negative, undetectable so far. We are excited.
That’s so exciting.
CHAE: Yes.
You took someone near death to a clear health stance.
CHAE: Yes, he was in the ICU. Literally with his lungs filled with cancer cells. I personally, did not believe he was going to make it out of ICU, but he was taken to surgery room and got two new lungs.
This all hit during the pandemic?
CHAE: Right. That was a difficult piece, too. That delayed a lot of my patients’ care, including his care. Still, I think there is a light at the end of the tunnel. I think one motivation he had, was that he saw a news story of patients getting double lung transplant done at our center. Those were young patients with destroyed lungs from COVID. We were the first center to do a double lung transplant for COVID destroyed lungs. He saw the news and he thought, “Why can’t it be me? I know I’m a cancer patient, but why can’t it be me?” He was very persistent in asking that wherever he went. He was thankful because we were the first team to really take on his wish and make it happen.
So, in a way, this is a lesson?
CHAE: Yes. This is a rare case of hope. The dream come true kind of story. I think it doesn’t hurt to ask. You should let everything in your chest and have doctor really give you an opinion about it. I think it’s good for you. I think that the lesson is, it’s interaction. That’s how I felt too. The first day, I said flat no. It was an advanced cancer is a contraindication. In the end, we were able to make this happen as a team, so it wouldn’t hurt to ask. We also need to understand this is a rare condition. For those cancer patients with distant spread, metastases, to other organs, that organ transplant may not be a great solution. But I specialize in experimental therapeutics. I’ve seen therapies, medical therapies, not surgery, being able to offer them durable remission, and only God knows how long they’re going to live. They’re still living a normal lifestyle, many years, with the help of new, novel therapeutics. You can still have hope and you can ask any question you want, and we’ll work together.
Anything else I’m missing on this one?
CHAE: I would add that we talked about lung cancer, but we envision a future, and it will be a near future for our team, that if you have any tumor contained to one organ, whether it be lung or liver, and there’s no spread to outside organ, I think transplant could be an option going forward.
Do you think that’d be kind of helpful for something like liver cancer?
CHAE: Yes.
Tell us how Albert became a patient here at NM.
BHARAT: Albert presented to our medical oncologist, Dr. Chae was treating him, and he had come to him with a bad problem, pretty advanced lung cancer, had failed all the chemotherapy. Dr. Chae took ownership of his care and put him on a bunch of different clinical trials, and so forth. Once everything had failed and he was going to the point of developing failure of his lungs, he was on a ventilator. We had been discussing this topic in our multidisciplinary program and had developed an operative strategy to safely do this. However, it was a coincidence that Dr. Chae ran into me during lunch and I felt Albert could benefit from this.
Up until Albert, how many lung cancer lung transplants had we done at Northwestern?
BHARAT: We had never done a transplant for a lung cancer patient.
Is it common for someone with stage 4 lung cancer to get a lung transplant?
BHARAT: Certainly, when patients have been diagnosed with a stage four cancer, it’s considered a complete no-no. As we started to put our minds together, we realized that the stage four cancer that he had was clearly within the chest, and we could absolutely clear all that infection and the cancer and save his life.
Why aren’t lung cancer patients typically candidates for a lung transplant?
BHARAT: One of the biggest fears of transplanting anybody who has cancer is the risk of recurrence after the transplant. All transplant patients will require medications to control their immune system, and that has an immunosuppressive effect. The concern is that if you suppress someone’s immune system and if they have lingering cancer cells in the body, those will flare up very quickly.
How was the transplant, and how difficult was it?
BHARAT: You can imagine trillions of these cancer cells all over both his lungs, and we had to take very meticulously all of that out within that six-hour time constraint that we typically have for re-implantation of new lungs without spilling a single cell into his chest cavity or into his bloodstream. It was an exciting night.
How is Albert doing today?
BHARAT: Last week when I saw him, I could not even tell that he had something as big as a double lung transplant. No oxygen. He had a smile when he came to see me in clinic, and he was just so grateful that he is back with his family. One of the most satisfying things for me, personally, to hear was the feeling that he described that he could now finally breathe.
How rare is a lung cancer lung transplant? Do you know how many of these have been done in the U.S.?
BHARAT: It’s extremely uncommon. There have been very few reports that have been described. Certainly not to the extent that Albert’s cancer was. I truly believe that a lot of those prior reports were not considered to be successful because I think the tools that are required to determine systemic disease when someone has stage four cancerhave improved a lot. Our ability to treat cancer has improved a lot, and our decision-making has improved a lot.
Do you think Albert will be the last one for Western medicine?
BHARAT: I hope Albert is not the last one. We are in the process of starting what we call a registry, where we will be able to hopefully help patients from across the country who are in a similar situation. We’ve developed a very nice set of protocols to take care of these kind of patients. Once they meet all those criteria, we’ll be able to list them for transplant and hopefully save their lives. Sometimes it takes creative thinking and just challenging the traditional paradigms to help patients like Albert. I’m just so grateful that we have the right team that is willing to just think outside the box and ask the question and push the boundaries to help patients like Albert.
END OF INTERVIEW
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